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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 /> printoutsfrom tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MANTECA SHELL I Date of Testing: 04-30-09 <br /> Facility Address: 824 E.Yosemite Avenue Manteca CA 95336 <br /> Facility Contact: Ernie Song Phone: 209-825-7722 <br /> Date Local Agency Was Notified of Testing: 04-24-09 <br /> Name of Local Agency Inspector(ifpresent during testing): Muniappa Naidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum ❑Other <br /> Test Equipment Used: Standard Measure Tape„ Equipment Resolution: <br /> ,. - - <br /> Identify Spill Bucket(By Tank Tl: Unleaded Fill T2: Unleaded Plus T3: Super Unleaded <br /> Number,Stored Product, etc.) Bucket Fill Bucket Fill Bucket <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury 0 Direct Bury <br /> ❑Contained in Sump 0 Contained in Stunp 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 131/a" 13'/2" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 2min. 2min. 2min. <br /> Test Start Time(Tt): 1:17p.m 1:18p.m 1:20p.m <br /> Initial Reading(R): 11%11 121/4" 12 1/16" <br /> Test End Time(TF): 2:25p.m 2:26p.m 2:28p.m <br /> Final Reading(RF): Il '/<" 12'/" 12 1/16" <br /> Test Duration(TF-Tt): lbr.8min. 1hr.8min. lhr.8min. <br /> Change in Reading(RF-R): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1116" 1/16" 1/16" <br /> Test Result: X Pass ❑Fail X Pass 0 Fail X Pass ❑Fail 0 Pass .D Fail <br /> Comments — (include information on repairs made prior to testing, and reconinvended follow-ap for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSHILE 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 Signaq e��f t eZ- Date:04-30-09 <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 />