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R E C B \. IE --- D <br />JUL 16 2013 <br />ENVIRONMENTAL <br />SWRCHjBALu-PN DEPARTMENT <br />Spill Bucket Testing Report Form <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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Rancho San Miguel Market Date of Testing: 06/20/18 <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: 6/14/18 <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: Brian MGPheely <br />Credentials1: ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:8822062 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Z Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape I Equipment Resolution:) /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 3 4 <br />02 - Prem <br />Bucket Installation Type: <br />E]Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury E]Direct Bury F-1Direct Bury <br />❑X Contained in Sump ❑ Contained in Sump ❑ 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 />1 min. <br />1 min. <br />Test Start Time (Ti ): <br />9:30am <br />12.30pm <br />Initial Reading (Ri ): <br />13.500 in. <br />9.0000 in. <br />Test End Time (TF ): <br />10:30am <br />1:30pm <br />Final Reading (RF ): <br />13.500 in. <br />9.0000 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 />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />© Pass ❑ Fail <br />❑X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />Comments: Replaced 91 Fill Adaptor due to 91 Bucket not passing - Retested & Passed <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all nthe Information contained in this report is true, accurate,and in full compliance with legal requirements. <br />I,l L, m <br />Technician's <br />Date: 06/20/18 <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 />