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06F10/2008 09:26 9163712450 BZ MANITANENCE PAGE 05/07 <br /> 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 /> printoutsfrom tests(if applicable),should be provided to the facill(v owner/operator,for submittal to the local regulatory agency. <br /> 1.. FACILITY INFORMATION <br /> Facility Name: COUNTRY MARKETPLACE Date of Testing: 3112/08 <br /> Facility Address: 1789 WF-ST CHARTER WAY,STOCKTON,CA <br /> Facility Contact: HARJINDER� I Phone: 209-933-1789 <br /> Date Local Agency Was Notified of Testing: 2/19/08 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: JAMES WILLIAMS <br /> Crcdcntials' X CSLB Contractor MCC Service Tech, r.lSWRCBTankTcster ❑Other(Specify) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> ufY Spill Bucket 1 87 � 2.„.,.. 91 ' ` 3, t Resolution: <br /> ldcn <br /> 'festE Equipment <br /> itBEAKER <br /> EAKER Auipmen <br /> 4 P <br /> 4 <br /> Number, ,Stored Product, etc. <br /> Bucket Installation T X Direct Bitty X Direct Bury ❑Direct Bury ❑Direct Bury <br /> Type: ❑Contained in Stunp ❑Contained in Sump ❑Contained in Sun ❑Contained in Sum <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 16 16 <br /> Wail time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TJ: 10:30 10:30 <br /> Initial Reading(R�: 500 500 <br /> Test End Time(i'r): 11:30 11:30 <br /> Final Reading(Rr): 500 500 <br /> Test Duration(TF—T,): 60 MINS 60 MINS <br /> Change in Reading(RF—R,) 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Ctitena: <br /> fest R ►It: X.Paas fJ ka1l 3C Pase f7; hr1 b1'asa; CiFstT ;: fl ttass `•Cf FaiP <br /> Comments-- (include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby ccrh 17 that aft Rhe infor on contained in oris report is true,accurate,and in full crnnpH=ce n*b legal requirements <br /> Technician's Signature: _ Date 1—2.- <br /> =L <br /> ' <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,to=]requirements <br /> may be more stringent. <br />