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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This forth is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (d applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Rales <br />Date of Testing: 07/10/18 <br />Facility Address: 4219 Morada Ln. Stockton, CA 95212- 11 <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 Rlviera DEC 2018 <br />`ik f*19l11111eZeI•], Y �:L[•i[•]:al.lY•].L5f:Y1L•1� <br />Company Name: Service Station Systems... <br />Technician Conducting Test: Kris Bell uEPARTMEW <br />Credentials: ® 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: Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: Measuring Tape <br />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 />❑X Contained in Sump <br />❑ Direct Bury <br />© Contained in Sump <br />❑ Direct Bury <br />❑x Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />15.00 in. <br />15.50 in. <br />15.75 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time (Ti) <br />9:53am <br />3:17pm <br />3:18pm <br />Initial Reading (RI ): <br />14.188 In. <br />13.750 In. <br />14.000 in. <br />Test End Time (TF ): <br />10:53am <br />4:17pm <br />4:18pm <br />Final Reading (RF ): <br />14.188 in. <br />13.750 in. <br />14.000 in. <br />Test Duration (TF -T 1): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF -RI ): <br />0.0000 in.0.0000 <br />in. <br />0.0000 in. <br />Pass/Fail Threshold or Crit e a: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />®Pass ❑ Fail <br />© Pass ❑ Fail <br />© Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments: 87 o ring pinched between bucket and sleeve. 7113 - 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, accurate,and in full compliance with legal requirements. <br />Technician's <br />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 />U <br />:ALTH <br />