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z, V <br />. <br />SWRCB, January 2006 <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 (if applicable), should be provided to the facility owner/operator for lttal to the local regulator �gey. <br />1. FACILITY INFORMATION <br />Facility Name: CHP Old Stockton Date of Testing: 6/28/2017 <br />Facility Address: 3330 N. Ad Art Rd, Stockton, CA 95215 <br />Facility Contact: James Murray Phone: 209-943-8666 <br />Date Local Agency Was Notified of Testing: 6/23/2017 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Environmental Compliance Systems Inc. <br />Technician Conducting Test: Hamzah AbdaIlah <br />Credentials`: R1 CSLB Contractor Rl ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specie) <br />License Number(s): 956593 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic ❑ Vacuum Other <br />Test Equipment Used: Tape measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 <br />3 4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />8" <br />Bucket Depth: <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 m i n <br />Test Start Time (Ti): <br />9:40 <br />Initial Reading (Ri): <br />10 1/4" <br />Test End Time (TF): <br />10:40 <br />Final Reading (RF): <br />10 1/4" <br />Test Duration (TF — Ti): <br />1 hr <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />2 Pass 0 Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />Comments — (include in 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: 6/28/2017 <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 />