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07/17/2012 18:36 <br />(209) 455-4988 MaryAnn Henderson Page 6/12 <br />• . <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is imendedfor use by contractors performing annual testing of UST spill contaimmAtstructures. The completedform and <br />primouis from tests (Ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACTT.TTV TNFnRMATTnN <br />Facility Name. ERNIE'S GENERAL STORE Date of Testing. 01/17/12 <br />Facility Address: 4407 E. WATERLOO RD, STOCKTON, CA 95215 <br />Facility Contact: MGR I Phone: 209-931-2850 <br />Date Local Agency Was Notified of Testing: 01/11/12 <br />Name of Local Agency Inspector (r(present during testing): GARRET BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: SERVICE STATION TESTING- SST, INC. <br />Technician Conducting Test. CHARLES FERRUCCI <br />CQentials': G CSLB Contractor X ICC Service Tech. 0 S WRCB Tank Tester G Other (Specify) <br />License Number(s): 5323096 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic G Vacuum 0 Other <br />Test Equipment Used: Water. Tape Measure, Stop Watch <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />I <br />REGULAR 87 <br />2 <br />PRENHUM 91 <br />3 <br />DIESEL <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />0 Contained in Sump <br />X Direct Bury <br />0 Contained in Sump <br />X Direct Bury <br />0 Contained in Sump <br />G Direct Bury <br />Cl Contained in Sum <br />Bucket Diameter: <br />12 <br />—11.25 <br />12 <br />12 <br />Bucket Depth: <br />121!2 <br />13 I2 <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN <br />5 MIN <br />5 MIN <br />Test Start Time (Ti): <br />1300 <br />1300 <br />1300 <br />Initial Reading (Ri): <br />10.75 <br />12 3/4 <br />12 1/4 <br />Test End Time (Te): <br />1400 <br />1400 <br />1400 <br />Final Reading (RF): <br />10.75 <br />12314 <br />12 114 <br />Test Duration (TF — T): <br />1 HR <br />1 HIR <br />I HIR <br />Change in Reading (RF -Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result: <br />X Pass G Fail <br />X Pass 0 Fal <br />X Pass0 Fail <br />0 Pass G Fan <br />C;OMMentS — (include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br />Water left on ite 'n dnlm at re of ctnre <br />CERTIFICATION OFTECHNIC RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby cer4i y that all the info 'on co d in this is true, ccurate, and ht full compliance with legal requirements. <br />Technician's Signature Date: 01/17/12 <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 />