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GEv REe <br />-.)j] ' WRC Lnuary2006 <br />Spill Bucket Testing Report FormN RONMENTAL <br />This form is intended for use by contractors performing annual testing of UST spill containment structytes XZM j mrdrld <br />printouts from tests (if applicable), should be provided to the facility ownedoperator for submittal tbt Jdhdh' <br />1. FACILITY INFORMATION <br />Facility Name: Relays 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: 6125/18 <br />Name of Local Agency Inspector (ffpmsentdunng testing): Stacy Riviera <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credentialsi: ® CSLB Contractor ® 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 ❑ Other <br />Test Equipment used: Measuring Tape <br />I Equipment Resolution:1/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re u <br />2 FIII Bucket 3 Fill Bucket <br />02 - Prem 03 - Diesel <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />E]Direct Bury ElDirect Bury <br />❑X Contained In Sump ®Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. 13.00 in. <br />Bucket Depth: <br />15.00 in. <br />15.50 in. 15.75 in. <br />Wait time between applying <br />vacuumtwater and start of test: <br />10 min. <br />10 min. 10 min. <br />Test Start Time T, ): <br />9:53am <br />3:17pm 3:18pm <br />Initial Reading (R ): <br />00.00 in. <br />13.750 in. 14.000 in. <br />Test End Time (TF ): <br />10:53am <br />4:17pm 4:18pm <br />Final Reading (PF) <br />00.000 <br />13.750 In. 14.000 in. <br />Test Duration (TF -T1): <br />1.00 hr. <br />1.00 hr. 1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 In. <br />0.0000 in. 0.0000 In. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS ZERO LOSS <br />Test Result: <br />❑ Pass ® Fail <br />® Pass ❑ Fail ®Pass ❑Fail <br />❑ Pass ❑ Fail <br />Comments: 87 o ring pinched between bucket and sleeve. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />thereby tartly that all the tn/ormadM eoytabred in this report1s true, aeeurate,and In full compliance with legal requirements. <br />Technician's <br />Date: 07/10/18 <br />I 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 />