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1 • • 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(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: RAPID SERVICE CENTER CARDLOCK Date of Testing: JUNE 27, 2006 <br /> Facility Address: 3550 HWY 99, STOCKTON, CA 95215 <br /> Facility Contact: MIKE ELIASON I Phone: 209.468-3420 <br /> Date Local Agency Was Notified of Testing: JUNE 16, 2006 <br /> Name of Local Agency Inspector(ifpresent during testing): TOUA YANG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: ROB NEIMEYER <br /> Credentials': E CSLB Contractor ❑ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 803705 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other(Specify) <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) REGULAR RED DIESEL <br /> Bucket Installation Type: E Direct Bury E Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 10.50" 10.50" <br /> Bucket Depth: 9.50" 10.00" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:00 AM 9:00 AM <br /> Initial Reading(Ri): 9.50" 10.00" <br /> Test End Time(TF): 9:30 AM 9:30 AM <br /> Final Reading(RF): 9.50" 10.00" <br /> Test Duration(TF—Ti): 30 MIN 30 MIN <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> I <br /> Test Result: E Pass ❑Fail E 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.n <br /> Technician's Signature: ll._—:----- Date: JUNE 27,2006 <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 />