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Spill Bucket Testing Report Form II IIII c <br />This toren is intended for use by contractors performing annual testing of UST spill containment structures. The completed fortsI}/rltl 16 Z O 16 <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 `b: • e. •� L.. . - - <br />FacilityName: Rancho San Miguel Market Date of Testing: 06/16/16 <br />Facility Address: 1409 S. Airport Way Stockton, CA 95206- <br />Facility contact: Jesus Jurado (209) 942-2840 <br />Date Local Agency Was Notified of Testing: 5/13/16 <br />Name of Local Agency Inspector (if present during testing): Stacy Rivera <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: M ke Briggs <br />Crecientialst: ® CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tesler ❑ Other (Specify) <br />License Number(s): License: 485164 ICC:8033115-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: Measuring Tape Equipment Resolution:1/16 In. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />02 - Prem <br />3 <br />4 <br />Bucket Installation Type: <br />E]Direct Bury <br />❑ x Contained In Sump <br />E]Direct Bury <br />❑X Contained In Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained In Sump <br />Bucket Diameter: <br />11.00 in. <br />11.00 in. <br />Bucket Depth: <br />13.00 in. <br />13.50 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />5 min. <br />Test Start Time IT, ): <br />9:00am <br />9:00am <br />Initial Reading (R, ): <br />12.000 in. <br />12.500 in. <br />Test End Time (TF): <br />10:00am <br />10:00am <br />Final Reading (P,): <br />12.000 in. <br />12.500 in. <br />Test Duration (TF - T 1): <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 in. <br />0.0000 in. <br />PasStll` I Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />❑X Pass ❑Fail <br />Pass ❑Fail <br />❑ Pass ❑ Fail I <br />❑ 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 thenformation contained in this report is true, accumte,and In full compliance with legal requirements. <br />i <br />�R 06/16/16 <br />Technician's Signature: Date: <br />t 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 />