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SWRCB,January 2006 <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 /> 4. FACILITY INFORMATION <br /> Facility Name: TIME OIL#04-049 1 Date of Testing: APRIL 21,2006 <br /> Facility Address: 14000 E. HWY 88, LOCKEFORD,CA 95237 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: APRIL 11, 2006 <br /> Name of Local Agency Inspector(ifpresent during testing): LORI LUCES <br /> 5. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: ROB NEIMEYER <br /> Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705 <br /> 6. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other(Spec) <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank I 2 3 4 <br /> Number, Stored Product, etc.) DIESEL FILL <br /> Bucket Installation Type: ® Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 10.50" <br /> Bucket Depth: 11.00" <br /> Wait time between applying 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1:30 PM <br /> Initial Reading(Rt): 10.50" <br /> Test End Time(TF): 2:00 PM <br /> Final Reading(RF): 10.50" <br /> Test Duration(TF—Tt): 30 MIN <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or Criteria: <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: 6Q-1�1 - Date: APRIL 21, 2006 <br /> 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 />