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�r <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisform is intended for use by contractors performing annual testing of USTspill containment structures. The completed form and <br /> printouts from tests('(applicable),should beprovided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: VANCO TRUCK&AUTO PLAZA Date of Testing:6/28/16 <br /> Facility Address: 1033 W.CHARTER WAY,STOCKTON <br /> Facility Contact MIKE <br /> *****ALL BUCKETS FAILED BESIDES THE DIESEL SOUTH <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test:FRED BABEL <br /> Credentials: CSLB Contractor X ICC Service Tech. S WRCB Tank Tester Other(Specify) <br /> License Number(s):ICC 00025547 <br /> 3. SPn L BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic Vacuum Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 DIESEL SOUTH 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12 <br /> Bucket Depth 15 <br /> Wait time between applying 10 <br /> vacuum/water and start of test: <br /> Test Start Time(T�: 12 <br /> Initial Reading(R,): 101/4 <br /> Test End Time(Tr): I <br /> Final Reading(RF): 15 <br /> Test Duration(Tv—T,): 1 HOUR <br /> Change in Reading(Rr-R,): NO <br /> Pass/Fail Threshold or PASSED <br /> Criteria: <br /> Test Result: - X Pass ❑Fail ❑ Pass ❑Fail ❑ Pass 0 Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing,and recommended follow-up forfailed tests) <br /> WILL COMPLETE FORM SEE INSPECTION FOR SR0075199 — 7/26/2016 <br /> CERTIFICAT ON OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the njorma ' r contained in this repart is true,accurate,and in full co p lance r ith legal requirements. <br /> Technician's Signature: 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. <br />