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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 ownerfoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Rancho San Miguel Market Date of Testing:6/6/13 <br /> Facility Address; 1409 S. Airport Way Stockton, CA 95206- <br /> Facility Contact: Gilbert Silva (209) 942-2840 <br /> Date Local Agency Was Notified of Testing: 5/29/13 <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: Kris Bell <br /> Credentials: [3] CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ©vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> dentify Spilt Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number, Stored Product,etc) 01 Re u 02 Prem <br /> Bucket Installation Type; [3Direct Bury E] Direct Bury E] Direct Bury ❑ Direct Bury <br /> X® Contained in Sump ®Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 13.50 in. 15.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. <br /> Test Start Time(Ti): 9:36am 9:36am <br /> Initial Reading(RI ): 12.000 in. 13.188 in. <br /> Test End Time(TF}: 10:36am 10:36am <br /> Final Reading(FF): 12.000 in. 13.188 in. <br /> Test Duration(TF-Tr): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: © Pass ❑ Fail © Pass ❑ Fail ❑ Pass ❑Fail ❑ 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 the Information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date;6/6/13 <br /> 1 State taws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />