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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: 76 1 Date of Testing: 10-8-09 <br />Facility Address: 574 W. Grantline Rd, Tracy, CA <br />Facility Contact: Ramesh Phone: (510)828-2266 <br />Date Local Agency Was Notified of Testing : <br />Name of Local Agency Inspector (ifpresent during testing): Michelle Henry <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: HMC- Henderson Maint Co <br />Technician Conducting Test: Gavin Williams <br />Credentials: ❑ CSLB Contractor [X] ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 8016288 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: [X] Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Water Equipme:.t'?���! <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1-91 <br />2-87 <br />3 <br />4 <br />L2irket Installation Type: <br />X Direct Bury <br />Contained in Sump <br />X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sum <br />Bucket Diameter: <br />11" <br />11 11 <br />Bucket Depth: <br />15" <br />15 %Z" <br />Wait time between applying <br />vacuum/water and start of test: <br />1 hr <br />1 hr <br />Test Start Time (Ti): <br />9:30 <br />9:30 <br />Initial Reading (&): <br />14 1/8" <br />14 %Z" <br />Test End Time (170: <br />10:30 <br />10:30 <br />Final Reading (RF): <br />0 <br />0 <br />Test Duration (TF— Tj): <br />I hr <br />I hr <br />Change in Reading (RF - R;): <br />0 <br />0 <br />Piss/Fail Threshold or <br />Criteria: <br />P <br />p <br />Test Result: <br />X Pass ❑ Fail <br />X 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 />rut used water in Drum (with Haserdous Waste Label) behind store <br />CERTIFICATION OF TECHNi%iAN R-JESPONSi_�;Lr. FCf:� a^i°_ l��il.11iv�� THIS TZST j -I +G <br />hereby certify that all the information contained in this report is true, accurate, and in full compliance with <br />legal requirements. Technician's Signature —1 Date:t/1'�/ <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local <br />rn—*#n —.a, ho -- e+r;"—* <br />