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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractorsperforming annual testing of UST spill containment structures. The completedform and <br /> printouts from tests(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Country Market Place I Date of Testing: 3-12-08 <br /> Facility Address: 1789 W.Charter Ave Stockton <br /> Facility Contact: Hmjinder Phone: 209-933-1789 <br /> Date Local Agency Was Notified of Testing : 2-19-08 <br /> Name of Local Agency Inspector(ifpresent during testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: James A.Williams <br /> Credentials: X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Spec) <br /> LicenseNumber(s): 433159 5252274 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Beaker I Equipment Resolution: 0 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3.... 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury 0 Direct Bury 0 Direct Bury <br /> ❑Contained in Sump 0 Contained in Surap 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 16 16 <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 10:30 10:30 <br /> Initial Reading(RJ: 500 500 <br /> Test End Time(TF): 11:30 11:30 <br /> Final Reading(RF): 500 500 <br /> Test Duration(TF—T,): 60 Min 60 Min <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result:. . X Pass E Fail X Pass O Fail 0 Pass 11 Fail . ❑Pass El Fail <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 /> 7 hereby certify that all the ' orma contained in this report is true,accurate,and in full compliance with legal requirements. <br /> � � <br /> Technician's Signature: - - Date:-3-12-08— <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 />