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Spill Bucket Testing Report For <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Teichert & Sons I Date of Testing: 10/22/08 <br /> Facility Address: 120 Frank West Circle, Stockton, CA 95206 <br /> Facility Contact: Steve I Phone: (916) 386-3767 <br /> Date Local Agency Was Notified of Testing: 10/09/08 <br /> Name of Local Agency Inspector(if present during testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Alvin L. Milburn <br /> Credentials' ®CSLB Contractor ICC Service Tech. - SWRCB Tank Tester Other(Specify) <br /> License Number(s): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: O Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: 1 Hr. Lake Test Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc.) C-1 Diesel Fill C-2 Gas Fill Waste Oil Fill <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 16" 16" 12" <br /> Bucket Depth: 15" 15" 15" <br /> Wait time between applying 5 min 5 min 5 m i n <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 14:30 14:30 14:45 <br /> Initial Reading(Ri): 14" 13.75" 13.25" <br /> Test End Time(TF): 15:30 15:30 15:45 <br /> Final Reading(RF): 14" 13.75" 13.25" <br /> Test Duration(TF—TI): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: 0 Pass 0 Fail ®'Pass ❑Fail tXI Pass ❑Fail ❑Pass ❑Fail <br /> Comments—(include information 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 the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 10/22/08 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />