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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 submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tracy Petro, Inc Date of Testing: 1-22-07 <br /> Facility Address: 3400 N. MacArthur, Tracy, CA 9535Willie <br /> Facility Contact: Karam Date Local Agency Was Notified of Testing: 7 <br /> Name of Local Agency Inspector(ifpresent during testing): Ng <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Dialysis North P.O. Box 994434, Redding, CA 96099 (530)229-1906 <br /> Technician Conducting Test: Greg Hartman <br /> Credentials: 11CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 5243869-UT - 03-1640 _ <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic E Vacuum ❑Other <br /> Test Equipment Used: MTS Mag Probe wi TDU Meter Equipment Resolution: .001" <br /> Identify Spill Bucket(By Tank <br /> # 1 -91 # 2— Diesel # 3 - 87 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: <br /> F]Direct Bury Ll Direct Bury -.Direct Bury <br /> X Contained in Sump X Contained in Sum X Contained in Sum <br /> Bucket Diameter: 11" 11" 11" <br /> Bucket Depth: 1 15" 15" 15" <br /> Wait time between applying 10 Min. 10 Min. 10 Min. <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 10:58 10:11 15:18 <br /> Initial Reading(R,): 0.000" 0.000" 0.000" <br /> Test End Time(TF): 11:22 11:22 15:42 <br /> Final Reading(RF): 0.004" 0.004" 0.000" <br /> Test Duration(TF—T,): 24 Min. 24 Min. 24 Min. <br /> Change in Reading(RF-R,): .004" .004" .000" <br /> Pass/Fail Threshold or +/-.004" +/_ 004" +/- .004" <br /> Criteria: - <br /> Test Result: X Pass ❑ Fail X Pass ❑Fail X Pass 11 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:—.161/ ASL <br /> ed _ Date: <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. Page 1 of I <br />