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JUN 2 9 2016 <br /> SWR,( W&mayZ <br /> Spill Bucket Testing Report Form <br /> This form Is intended for use by on, per/orming annual testing of UST sp11 containment structures. The completed to"and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator/or submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Mobil/Tesoro Date of Testing:06/01/16 <br /> Facility Address: 2500 W. Lodi Lodi, CA 95242 <br /> Facility Contact: Mona (209)366-0703 <br /> Date Local Agency Was Notified of Testing: 5/2)16 <br /> Name of Local Agency Inspector (if present during testing): Aris Veloso <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialsi: ❑X CSLB Contractor NX ICC Service Tech. ❑SWRCB Tank Tester ❑ Other(Spechy) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic N Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (B Te <br /> 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 Fill Bucket <br /> Number,stared product,etc.) 01 - Re u 02-Plus 03- Prem 04-Diesel <br /> Bucket Installation Type: ❑Direct Bury E]Direct Bury N Direct Bury E] Direct Bury <br /> ❑X Contained in Sump ❑x Contained In Sump ❑x Contained in Sump © Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. 14.00 in. 14.00 in. <br /> Walt time between applying 5 min. 5 min. 5 min. 5 min. <br /> vacuumiwater and start of test: <br /> Test start Time(TI): 10:30am 10:30am 10:30am 10:30am <br /> Initial Reading(R, ): 13.000 in. 13.000 in. 13.000 in. 13.000 in. <br /> Test end Time(TF): 11:30am 11:30am 11:30am 11:30am <br /> Final Reading(RF): 13.000 in. 13.000 in. 13.000 In. 13.000 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr, 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-RI): 0.0000 in. 0.0000 In. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS ZERO LOSS <br /> at <br /> Result; [81 Pass ❑ Fail ©Pass ❑ Fail I ❑X Pass [I Fail I NX 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 lnforRnatlon contained in this report is true,accurate,and/n full compliance with legal requirements. <br /> Technician's Signature: L' rel yk _ Data,06/01/16 <br /> t 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 />