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5 <br /> 'v <br /> !�,Y 20A6CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment strut#tires. 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:DP&DK INV.INC. Date of Testing:5/3/2017 <br /> Facility Address: 1206 E.MARCH LANE MARCH LANE SHELL,STOCKTON,CA 95210 <br /> Facility Contact:KARAM SINGH Phone:510-926-7834 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentialsl: r— CSLB Contractor � ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: IW Hydrostatic r vacuum r Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank 1 Spill Box#Tank 2 Spill Box#Tank 3 Diesel- <br /> Number, Stored Product, etc) REGULAR-Fill 1 -Direct- PREMIUM-Fill 1-Direct- Fill I -Direct-Grade level Spill Box# <br /> Grade level Grade level <br /> l Direct Bury f: Direct Bury ro Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump r Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.00 14.00 10.50 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 08:30:00 08:30:00 08:30:00 <br /> Initial Reading(R1): 11.00 in.H2O 13.00 in.H2O 10.00 in.H2O <br /> Test End Time(TF): 09:30:00 09:30:00 09:30:00 <br /> Final Reading(RF): 11.00 in.H2O 13.00 in.H2O 10.00 in.H2O <br /> Test Duration(TF—TI): I hr 1 hr 1 hr <br /> Change in Reading(RF—R,): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THLS 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 Signature: All eL- Date: 5/3/2017 <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2331996 <br />