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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor 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 Date of Testing:2/27/2015 d <br /> Facility Address:3400 N.MACARTHUR DR,TRACY,CA 95376 <br /> Facility Contact:KARAM SINGH Phone:209-814-8581 `- <br /> Date Local Agency Was Notified of Testing: - <br /> Name of Local Agency Inspector(ifpresent during testing):unknown <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Jarrod Cooke <br /> Credentialsl: r CSLB Contractor W ICC Service Tech. r—, SWRCB Tank Tester r Other(Specify) <br /> License Number(s):5311523 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic r Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank Tl Spill Box N"tank"I2 Spill Box Nank 1'3 Diesel- <br /> Identify Spill Bucket(By Tank PREMIUM-Fill 1 -Direct- REGULAR-Fill I -Direct- Fill 1 -Direct-Grade level Spill Box# <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment <br /> in containment sump <br /> sump sump <br /> f:-' Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: 6 Contained in Sump r- Contained in Sump r Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.50 12.50 12.50 <br /> Wait time between applying <br /> vacuum/water and start of test 5 min 5 min 5 min min <br /> Test Start Time(TI): 09:00:00 09:11:00 09:17:00 <br /> Initial Reading(RI): 12.50 in. 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 10:00:00 09:12:00 09:18:00 <br /> Final Reading(RF): 12.50 in. 29.00 in.H2O 29.00 in.H2O <br /> Test Duration(TF—TI): 1 hr 1 min I min <br /> Change in Reading(RF—RI): 0.00 in. -1.00 in.H2O -1.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for jailed 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: 2/27/2015 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements maybe more stringent. <br /> WO:2322332 <br />