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�r!LiL7 E--LD) <br /> AIL 11 1 2008 SWRCB,January 2006 <br /> ENVIRONPA[1u THEALTH Spill Bucket Testing Report Form <br /> This fi�W 4ipt�,c�$0PFse by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(f 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 <br /> Facility Address: 1427 S. Airport Way,Stockton,CA 95206 Date of Testing: July I6,2008 <br /> Facility Contact: Gilbert Silva Phone: 992-7620 <br /> Date Local Agency Was Notified of Testing : 7114/2008 <br /> Name of Local Agency Inspector(afpresent during testingl: Ray von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC, <br /> Technician Conducting Test: Mike Jones <br /> Credentials`: ❑CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 5254644-UT and 5252537-U1 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑ Vacuum <br /> ❑Other <br /> Test Equipment Used: <br /> 1?quipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 <br /> Number, Stored Product, etc.) Re ular-Unlead 4 <br /> Bucket Installation Type: ❑'Direct Bury ❑Direct Bury Li Direct Bury ❑Direct Bu <br /> ry <br /> x Contained in Sump IJ Contained in Sump ❑Contained in Sum ❑Contained Sum <br /> Bucket Diameter: III, <br /> Bucket Depth: 13-14" <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:15 a.m. <br /> Initial Reading(R[): 13-1/4" <br /> Test End Time(Tr): 10:15 a.m. <br /> Final Reading(RF): 13-114" <br /> Test Duration(TF—Tj): One Hour <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold or <br /> Criteria: Pass <br /> Test Result: x Pass ❑ Fail ❑ Pass ❑ Fai! 11Pass CI Fail <br /> ❑ Pass [] Fail <br /> Comments— (include information on repairs made prior to testing, and recammended follow-up for failed tests) <br /> INSTALLED NEW OPW C05097N, DATE MFG. 07-07 <br /> TESTED 1-1/2" FROM TOP <br /> DRAIN VALVE PASSED <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report A true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature: 'Alike_Tames Date: July 16,2008 <br /> 1 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 />