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Spill Bucket Testing Report Form SWRCB,January 2008 <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 owneUoperetor for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> r-acility Name: Rancho San Mlgtic Dxe otTeshng' 10/25/16 <br /> -----. __. ..,. ...._ .... _.a-_W_r..__.. ........-...............� <br /> Facility Address: 610 S. Cherokee Ln Lodi, CA 9524p <br /> Facility Contact: Jesus Jurado 209 339-8200 <br /> Dale Local Agency Was Notified of Testing: 10!7/16 <br /> Name of Local Agency Inspector (it present during testing): Fatinah Zareef <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialsi: ©CSLB Contractor ® ICC Service Tech. ❑SWRCB Tank Tesler ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used I@ Hydrostatic ❑Vacuum ❑ Other <br /> r1dentIfy <br /> uipment Used: Measuring Tape Equipment Resolutlon:1/16 in. <br /> Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> ,Stored Product,etc) 0 -Re u 02-Prem <br /> nstallation Type, ❑ Direct Bury ❑ Direct Bury ❑Direct Bu ry <br /> ry ❑ Direct BuContained In Sump ®Contained In Sump ❑ Contained in Sump ❑ Contained In Sump <br /> ucetDlameter. 13.00 in. 13.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. <br /> Wait time between applying <br /> vacuum/water and star of lest: 5 min. 5 min. <br /> Test Start Time IT,): 930a 9:30am <br /> Initial Reading(RI): 12.750 in. 12.750 in. <br /> Test End Time(TF): 1030a 10:30am <br /> Final Reading(F(<): 12.750 in. 12.750 in. <br /> Test Duration IT,-T 1): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. 0.0000 in. <br /> Pass/Fall Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: p Paas ❑Fail ®PariS ❑ Fell ❑pass ❑Fall ❑Pase ❑ Feil <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 Info tion contalned in this report Is true,accurateand in full compliance with legal requirements. <br /> Technician's Signature: Date: 10/25/16 <br /> t Stale laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be mon:stringent. <br />