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200 VRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill 4ontainment structures. The completegform and <br /> printouts from tests (if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Raleys Date of Testing: 8-4-17 <br /> Facility Address: 4219 Morada In Stockton <br /> Facility Contact: Dawn Phone: 209-956-9300 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Service station systems <br /> Technician Conducting Test: Brian McPheely <br /> Credentials': 0 CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester 0 Other(Specify)_____ <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum 0 Other <br /> Test Equipment Used:WATER Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 3 4 <br /> Number,Stored Product, etc.) <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury 0 Direct Bury 0 Direct Bury <br /> X Contained in Sump 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump <br /> Bucket Diameter: 12 <br /> Bucket Depth: 15 <br /> Wait time between applying 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:40AM <br /> Initial Reading(RO: 13% <br /> Test End Time(TF): 12:40PM <br /> Final Reading(RF): 13 % <br /> Test Duration(TF—Tj): 60 MIN <br /> Change in Reading(RF-Rt): 0 <br /> Pass/Fail Threshold or NO VISUAL <br /> Criteria: <br /> Test Result: j X Pass 0 Fail 0 Pass 0 Fail 1 0 Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Replaced 87 spill bucket outer upper casket and tested. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: �,� 'l �� i J Date:_84-17 <br /> 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 />