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• <br />• RECEIVED <br />JUL 2 r 2017 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form ENVIRONMENTAL HEALTH <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The comp/ettltfdrr6>(n'rP M E NT <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />7 CArll ITV INF(1PI111 CIN <br />Facility Name: Rancho San Miguel Market <br />Date of Testing: 06/22117 <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: 5/25/17 <br />Name of Local Agency Inspector (ifpresent during testing): Victoria McCartney <br />4 TP4Tl Nr9 rr1NTRACTOR INFORMATION <br />Company Name:Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credenflalsf: Q CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): Limnse:485184 ICC:5297793-UT <br />3 CPII I RI IrKFT TFRTINr. INFORMATION <br />Test Method Used: <br />❑X Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />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 />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />13.00 In. <br />13.00 In. <br />Bucket Depth: <br />14.50 in. <br />13.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />Test start Time (r, ): <br />EIA5am <br />11:13am <br />Initial Reading (R, ): <br />12.000 in. <br />11.313 in. <br />Test End Time (TF ): <br />10:45am <br />12:13pm <br />Final Reading (PF ): <br />12.000 in. <br />11.313 in. <br />Test Duration (TF -T,): <br />1.00 hr. <br />1.00 hr. <br />Reading (RF • R, ): <br />0.0000 in. <br />0.0000 in. <br />Ehao <br />7hreshold or Criteria: <br />ZERO LOSS <br />I ZERO LOSS <br />Test Result: <br />®Pass ❑Fail <br />®Pass Q Fall <br />❑Pass ❑Fail <br />❑Pass ❑Fall <br />Comments: Prem failed due to bad cap changed cap retested <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the InjUmatirtn co <br />tatned in this report is true, accurate,and In full compliance with legal requirements. <br />Technician's <br />Date: 06/22/17 <br />I 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 />