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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: Raleys Date of Testing:07/10/18 <br /> Facility Address: 4219 Morada Ln. Stockton, CA 95212- <br /> Facility Contact: Dawn Dircksen (209) 956-9300 <br /> Date Local Agency Was Notified of Testing: 6/25/18 i <br /> Name of Local Agency Inspector (if present during testing): Stacy Riviera <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... ENVIRONMENT <br /> Technician Conducting Test: Kris Bell HEALTH DEP <br /> Credentialsi: ©CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8833000 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [X Hydrostatic ❑ Vacuum [j Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number, Stored Product,etc.) 01 - Re u 02 - Prem 03 - Diesel <br /> Bucket Installation Type: E] Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑X Contained in Sump ❑X Contained in Sump ❑X Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 15.50 in. 15.75 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 10 min. 10 min. 10 min. <br /> Test Start Time(T,): 9:53am 3:17pm 3:18pm <br /> Initial Reading(R, ): 14.188 in. 13.750 in. 14.000 in. <br /> Test End Time(TF): 10:53am 4:17pm 4:18pm <br /> Final Reading(Pf): 14.188 in. 13.750 in. 14.000 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS I ZERO LOSS ZERO LOSS <br /> Test Result: ® Pass ❑ Fail 1 © Pass ❑ Fail © Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: 87 o ring pinched between bucket and sleeve. 7/13 - Installed Ouing and Cap on 87 - Rested & Passed <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the info n co ained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 07/10/18 <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 />