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SWRCB, January 2006 <br />Spill Bucket Testing Report Form MAR 2 5 2016 <br />This form is intended for use by contractors performing annual testing of UST spill containment structu"t&lp-com)�IeO form and <br />printouts from tests (if applicable) should be provided to the facility owner/operator for submittal to t regulatwy agency. <br />FACILITY INFORMATION <br />Facility Name: VALLEY PACIFC COUNTRY MARKET Date of Testing: 311112016 <br />Facility Address: 1524 FRESNO AVENUE, STOCKTON, CA 95206 <br />Facility Contact: MIKE ELIASON Phone: (209) 948-9412 <br />Date Local Agency Was Notified of Testing: 2118116 <br />Name of Local Agency Inspector (ifpresent during testing): STACEY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials[: ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 (CSLB Contractor) — 5254736 -UT (/CC Service Tech.) — 06-1672 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: VISUAL - TAPE MEASURE <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />DIESEL FILL <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />13.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 MIN <br />Test Start Time (Tt): <br />12:30 <br />Initial Reading (Rt): <br />12" <br />Test End Time (TF): <br />1:30 <br />Final Reading (RF): <br />12" <br />Test Duration (TF —Tj): <br />1 HR <br />Change in Reading (RF - Rt): <br />0 <br />Pass/Fail Threshold or Criteria: <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />'.fest Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ 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: �---Z ",{`_ � Date: 3111/2016 <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 />