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Spill Bucket Testing Report Form SWRCB,January 2006 <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 owneNoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION _ <br /> Facility Name: Rancho San Miguel Date of Testing: 10/25/16 <br /> Facility Address: 610 S. Cherokee Ln. Lodi, CA 95240- <br /> Facility Contact Jesus Jurado 209 339-8200 <br /> Date Local Agency Was Notified of Testing: 10!7/16 <br /> Name of Local Agency Inspector (if present during testing): Fatinah Zareef <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentlalsi: ❑X CSLB Contractor ® ICC Service Tech. ❑SVJRCB Tank Tesler ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ©Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolulion:1/16 in. <br /> Identify Spill Bucket (By Tenk Fill Bucket 3 4 <br /> Number,Stored Product,etc.) 01 -Re u 02-Prem <br /> Bucket Installation Typo: E] Direct Bury E] Direct Bury E] Direct Bury E] Direct Bury <br /> ®Contained In Sump ®Contained in Sump ❑ Contained in Sump ❑ Contained In Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. <br /> Wait lime between applying 5 min. 5 min, <br /> vacuum/water and start of lest: <br /> Test Start Time IT, j; 9:30am 9:30am <br /> Initial Reading(r1 ): 12.750 in. 12.750 In. <br /> Test End Time(TF): 10:30am 10:30am <br /> Final Reading(rk]: 12.750 In. 12.750 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -RI): 0.0000 in. 0.0000 In. <br /> Pass/Fall Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ®Pass ❑Fall - ® Pass ❑ Fall ❑Pass '❑Fall ❑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 cerfiy that all the lailarfflation contained In this report is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: Ak _ Date: 10/25/16 <br /> 1 Stale laws and regulations do not currently require testing lobe performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />