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SWRCB,January 2006 <br /> Spill Bucket Testing Report Farm <br /> This fom)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 provldod 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:6114112 <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; 617112 <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: Randy Wilkerson <br /> Credentials: ❑X CSLB Contractor 2 ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICc:5258560-UT <br /> 3, SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [iX Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment used: Measuring Tape Equipment Resolution:1116 in. <br /> Identify Spill Bucket (fay Tank 1 Fill Bucket 2 Fill Bucket 3 <br /> Number, Stored Product,etc.) 01 Re a 02 Prem <br /> ❑ Direct Bury E] Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> ❑ Contained in Sump 0 Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 In, 12.00 In. <br /> Bucket Depth: 13.00 in, 13.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 15 min. 1 5 min. <br /> Test Start Time(T ): 2:00pm 2:00pm <br /> Initial Reading(RI }: 11.500 in. 11.500 in. <br /> Test End Time(TF ): 3:00pm 3:00pm <br /> Final Reading(RF ): 11.500 in. 11.500 in. <br /> Test Duration(TF -T 1): 1.00 hr. 1.00 hr. <br /> Change in Rsading(RF -R}): 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ❑x Pass ❑ Fail Ej 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 /> 1 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:8114112 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,focal requirements <br /> may be more stringent. <br />