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11/05/2009 THU 8: 48 FAX 9163861256 A Teichert & Son Inc 0004/004 <br /> '10/28/2009 14:28 66139 CHUCK HILL PAGE 04/04 <br /> .�.,o <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY III(FORMA'TION <br /> Facility Name: Teichert E ment Date of.Testing- 09/25/2009 <br /> Facility Address: 120 Frank West Circie Stockton CA 95206 <br /> Facility Contact: Steve Schauman Phone: 916-3$6-3767 <br /> i)ate Local Agency Was Notiited of Testing: <br /> Name of.Local Agency Inspector(f present during testing): <br /> 2. TES'T'ING CONTRACTOR INFORMATION <br /> company Name: EPIC Com Itance S stems InG. <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 0 CSLB Contractor 4 TCC Service Tech. ®SWRCB Tank Tester q Other(Specify) <br /> Ticense Number($): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: U Hydrostatic U vacuum Q Other <br /> Test Equipment Used: I Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Diesel 2 UnleadEti 3 yWaa�ste Oil 4 <br /> Number;Stored Product, etc) <br /> ®Direct Bury D Direct Bury 0 Direct Bury El Direct Bury <br /> Bucket Installation Type: ®Contained in SumR M Contained in Surnp ®Contained in Sum ®Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 16" 16rr 16n <br /> Wait time between applying 5 minutes 5 minutes 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 10:30 AM 1.0:45 AM 01:45 PM <br /> Initial Reading(R,): 15 1/8" 14 7/8" 15" <br /> Test End Time(Tp): 11:30 AM 11:45 AM 02:45 PM <br /> Final Reading(Rr): 15 1/8" 14 7/8" 151, <br /> Test Duration(Tp-T,): 1 hour 1 hour 1 hour <br /> Change in Reading(Rp-Ri): 0 0 0 <br /> Rasa/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Comments^^.(include in•::.:...... .. frl�Att�a::;.:..<>i'<.,..:,,,.... •• :.::: °::: ... . ......:. ... ::!: <br /> . ormation on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all lite information contained In this reporr is true,accurate,and in fall compliance with legal requirements. <br /> . ,....�,.., ..-:s........ Date:—OP J25/2Q09 <br /> Technicians Signature: <br /> 'State laves and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />