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l^ ' r <br /> Fu. k.aca y <br /> JUL 0 5 2017 <br /> '"SWRCB,January 2008 7-1 <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(if applicable),should be provided to the facility owner/opemlor for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Mobil/Tesoro Date of Testing:06/21/17 <br /> Facility Address: 2500 W. Lodi Lodi, CA 95242 <br /> Facility Contact: Mona (209) 366-0703 <br /> Date Local Agency Was Notified of Testing: 5/24/17 <br /> Name of Local Agency Inspector (ifpresent during testing) Victoria McCartney <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Kris Bell <br /> Credentials: ®CSLB Contractor ® ICC Service Tach. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution://16 In, <br /> Identify Spill Bucket (Sy Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 Fill Bucket <br /> Number,Stored Product, etc.) 01 -Re u 02-Plus 03-Prem 04-Diesel <br /> Bucket Installation Type: E] Direct Bury ElDirect Bury E] Direct Bury ❑Direct Bury <br /> © Contained In Sump ©Contained In Sump QX Contained In Sump ©Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 13.00 in. 14.00 in. 14.00 in. 13.00 in. <br /> Wait time between applying 10 min. 10 min. 10 min. 10 min. <br /> vacuum/water and start of test <br /> Test Start Time IT,1: 11:19am 1:06pm 1:05pm 11:21 am <br /> Initial Reading IN): 11.688 in. 12.18B in. 12.000 in. 11.500 in. <br /> Test End Time(TF): 12:19pm 2:06pm 2:05pm 12:21 pm <br /> Final Reading(Pf): 11.688 in. 12.188 in. 12.000 in. 11.500 in. <br /> Test Duration(TF-Tl): 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/Fall Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: ® Pass ❑Fall ®Pass ❑Fail ®Pass ❑ Fail ®Pass ❑ Fail <br /> Comments: 89&91 Failed, Repaired & Retested <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the Infon co Inad in this report Is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: Date: 06/21117 <br /> f 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 />