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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisform 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: 209466-0833 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: okA i <br /> Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): lL',1 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test Equipment Used: H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 187 2 Diesel North 3 Diesel South 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 X Contained in Sump Contained in Sum <br /> Bucket Diameter: <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): <br /> Initial Reading(Rj): <br /> Test End Time(TF): <br /> Final Reading(RF): <br /> Test Duration(TF—Ti): <br /> Change in Reading(RF-Ri): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass X Fail Pass X Fail Pass X Fail ❑ Pass ❑Fail <br /> Comments — (include information on repairs Imide prior to testing, and recommended follow-up for failed tests) <br /> 87 bucket — Bad Gasket <br /> Diesel North Bucket— Bad Drain & Gasket <br /> Diesel South Bucket — Bad Drain <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: .sr /� %=6' '���ls Date: <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> maybe more stringent. <br />