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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 /> printouts from 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: Mobil/Tesoro Date of Testing:06/19/18 <br /> Facility Address: 2500 W. Lodi Lodi, CA 95242 <br /> Facility Contact: Mona (209) 366-0703 <br /> Date Local Agency Was Notified of Testing: 5/29/18 <br /> Name of Local Agency Inspector (if present during testing): Aaron Hang <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems.,. <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialsi: ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-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 (By Tank 1 Fill Bucket7�__ <br /> Fill Bucket 3 Fill Bucket 4 Fill Bucket <br /> Number, Stored Product,etc.) 01 -Re u Q2-Plus 03-Prem 04- Diesel <br /> E] Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> ❑X Contained in SumpX❑Contained in Sump ❑X Contained in Sump ❑X Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 12.00 in. 12.00 in. 12.00 in. 12.00 in. <br /> Wait time between applying 5 min. 5 min. 5 min. 5 min. <br /> vacuum water and start of test: <br /> Test Start Time(T,); 10:45am 10:45am 10:45am 10:45am <br /> Initial Reading(Ri ): 10.000 in. 10.000 in. 10.000 in. 9.2500 in. <br /> Test End Time(TF}: 11:45am 11:45am 11:45am 11:45am <br /> Final Reading(RF): 10.000 in. 10.000 in. 10.000 in. 9.2500 in. <br /> Test Duration(TF -Ti): 1,00 hr. 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 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 /> Test Result: ❑x Pass ❑ Fail ❑X Pass ❑ Fail ❑X Pass ❑ Fail © Pass ❑Fad <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 /> hereby certify that all the infor atlon contained In this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ok Date: 06/19/18 <br /> 1 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 />