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I I <br />• 9 <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <br />7Tits form is thtendedfor use by contractors performbig annual tesnhg of U'Srspill containment structures. rhe completedform and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FArTT.TTV TNTnDMA TTnM <br />-------_ - _.._ �.-........... <br />Facility Name: ERNIES GENERAL STORE Date of Testing: 1-15-13 <br />Facility Address: 4407 E. Waterloo Rd Stockton, Ca <br />Facility Contact: emit phone, <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (ifpresent during testing): Garrett brakus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Testing, Inc. <br />Technician Conducting Test: Charles Ferrucci <br />Credentials': ❑ CSLB Contractor ❑ ICC Service Tech ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 5323096 -UT <br />3. SPIT.I.RIICKF.TTF.ICTIN(1TNFnDMATrnN <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum 0 Other <br />Test Equipment Used: Water, Tape Measure, Stop Watch <br />Equipment Resolution: 1116" <br />Identify Spill Bucket (ay Tank <br />Number, Stored Product, etc.) <br />1 reg fill <br />2 prem fill <br />3 diesel rill <br />4 <br />Bucket Installation Type: <br />x Direct Bury <br />❑ Contained in Sump <br />%Direct Bury <br />❑ Contained in Sump <br />:t Direct Bury <br />❑ Contained in Sump <br />0 Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />12 <br />12,5 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />0900 <br />0900 <br />0900 <br />Initial Reading (R1): <br />10 <br />11 <br />12 <br />Test End Time (TF): <br />1 1000 <br />1 1000 <br />1000 <br />Final Reading (RF): <br />10 <br />11 <br />12 <br />Test Duration (TF — TO: <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF -R1): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result: <br />Pass ❑ Fail <br />X Pass ❑ Fail <br />X Pass ❑ Fail <br />❑ Pass ❑ Fail <br />COmment3 — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION O CLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that allthe in o in in this report true accurate, and in fu[[ comp[iane legal requirements <br />Technician's Signature: <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 />