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SWRCB,Jariu$(y 200,6(C <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 I Date of Testing: 07/20/17 <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: 6/29/17 <br /> Name of Local Agency Inspector (Ifpresent during testing): Victoria McCartney <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Myke Briggs <br /> Credentialsi: ❑X CSLB Contractor I] ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 CC:8033115-UT <br /> 3. SPILL BUCKET 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 TankFill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> 1 <br /> Number,Stored Product,etc.) 01 -Regu 02-Prem 03-Diesel <br /> E] Direct Bury ❑ Direct Bury ❑ Direct Bury E] Direct Bury <br /> Bucket Installation Type: <br /> ❑Contained in Sump ® Contained in Sump ❑X Contained In Sump ❑ Contained in Sump <br /> Bucket Dlameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 15.00 in. <br /> Wait time between applying 5 min. 5 min. <br /> vacuum/Water and start of test: <br /> Test StartTime Cr,): 2:30pm 2:30pm <br /> Initial Reading(R, ): 12.000 in. 12.000 in. <br /> Test End Time(rF): 3:30pm 3:30pm <br /> Final Reading(Pv): 12.000 in. 12.000 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-Ri): 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Teii Result: ❑Pass M Fall LXJ Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fall <br /> Comments: 87 Bucket Failed,will return, repair and retest.91 Fill Cap Replaced. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that al7the Information Contained In this report is true,accursta,and In full compliance with legal requirements. <br /> Technician's Signature: Data.07/20/17 <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 />