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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 />..zV:r- 7l allal113eT-7d,I_\i rel I <br />Facility Name: Raleys Date of Testing: 07113/18 <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 <br />Name of Local Agency Inspector (if present during testing): Stacy Riviera <br />r;lil7 11) ZU16 <br />9 TPSTINr; rnNTRACTr7R INFARMAT]nN <br />Company Name:Service Station Systems... FNVIRnNMENTAL <br />Technician Conducting Test: Kris Bell HEALTH DEPARTMENT <br />Credentialsi: ® CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:8633000 <br />3_ SPILL RACKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: Measuring Tape 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 Fill Bucket <br />02 - Prem <br />3 Fill Bucket <br />03 - Diesel <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained In Sump <br />E]Direct Bury <br />®Contained in Sump <br />E]Direct Bury <br />©Contained in Sump <br />E]Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />13.00 In. <br />Bucket Depth: <br />15.00 In. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />Test Start Time IT, ): <br />9:53am <br />Initial Reading (til ): <br />14.188 in. <br />Test End Time (TF ): <br />10:53am <br />Final Reading (F>): <br />14.188 In. <br />Test Duration (TF - T 1): <br />1.00 hr. <br />Change in Reading (RF - Rl ): <br />0.0000 In. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />Test Result: <br />® Pass ❑ Fail <br />E] Pass ❑ Fail <br />C] Pass E] Fail <br />❑ Pass ❑ Fail <br />Comments: 87 a ring pinched between bucket and sleeve. 7/13 - Installed Oring and Cap on 87 - Rested & Passed <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the infer contained In this report is true, occurate,and In full compliance with legal requirements. <br />Technician's <br />07113/18 <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 />