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UST <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 /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Fast&Easy Morada#60 Date of Testing:04/12/2018 <br /> Facility Address:10878 North Hwy 99 <br /> Facility Contact:Asim Phone:707-747-2955,ext.106 P <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Confidence UST Services <br /> Technician Conducting Test:Aaron Perrigo <br /> Credentials': V CSLB Contractor V ICC Service Tech. SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s):804904 8485827-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: VHydrostatic ❑Vacuum �]Other <br /> Test Equipment Used:Lake Test Equipment Resolution:0.0625" <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) Reg SUP-1 Sup-2 DSL <br /> Bucket Installation Type: V Direct Bury ;M Direct Bury id Direct Bury V Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11.00" 11.00" 11.00" 11.00" <br /> Bucket Depth: 14.00" 14.00" 14.00" 14.00" <br /> Wait time between applying <br /> 5 min 5 min 5 mn 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:15am 10:15am 10:15am 10:15am <br /> Initial Reading(RI): 10.50" 11.50" 11.75" 13.75" <br /> Test End Time(TF): 11:15am 11:15am 11:15am 11:15am <br /> Final Reading(RF): 10.50" 11.50" 11.75" 13.00" <br /> Test Duration(TF—Ti): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(RF-RI): 0.00" 0.00" 0.00" 0.75" <br /> Pass/Fail Threshold or <br /> 0.0625" 0.0625" 0.0625" 0.0625" <br /> Criteria: <br /> Test Result: Z Pass ❑ Fail E Pass ❑Fail 0 Pass ❑Fail ❑ Pass 0 Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for,failed tests) <br /> Tried cleaning drain valve and flushing retested and DSL spill bucket still failed hydrostatic testing. <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: � Date:04/12/2018 <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 />