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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 Names: Vanco Truck—Auto Plaza Date of Testing: 6/20/2018 <br /> Facility Address: 1033 W Charter Way Stockton Ca 95206 <br /> Facility Contact: Mike Boparai Phone: 209-466-0833 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: OGr-�Y`olta� <br /> Credentials': CSLB Contractor X ICC Service Tecli. SWRCB Tank Tester Other(Specify) <br /> License Number(s): �45 <br /> 3. SPILL BUCKET TESTING INFORMATION _ <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 100 Octane 291 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 14'/z" 14" <br /> Wait time between applying I0min 10min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9am 98m <br /> Initial Reading(RO: 13 %2" 12 7/8" <br /> Test End Time(TF): l0am 10am <br /> Final Reading(RF): 13 %2" 12 7/8" <br /> Test Duration(TF—Tj): 1 hr 1 hr <br /> Change in Reading(RF-Rj): No No <br /> Pass/Fail Threshold or Pass Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail Pass ❑Fail ❑ 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 Signatur oma— " Date: od <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 />