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0 • 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 completedform 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: SHANE&DAVES Date of Testing: JUN 23,2008 <br /> Facility Address: 3550 HWY 99, STOCKTON,CA 95215 <br /> Facility Contact: MIKE ELIASON Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: JUN 11, 2008 <br /> Name of Local Agency Inspector(ifpresent during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: ROB NEIMEYER <br /> Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 803705 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other(Spec) <br /> Test Equipment Used:VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 87 FILL RED DIESEL FILL <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury E] Direct Bury C]Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 10.50" 10.50" <br /> Bucket Depth: 11.00" 11.00" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:45 AM 9:45 AM <br /> Initial Reading(Rt): 11.00" 11.00" <br /> Test End Time(TF): 10:45 AM 10:45 AM <br /> Final Reading(RF): 11.00" 11.00" <br /> Test Duration(TF—Tt): 1 HR 1 HR <br /> Change in Reading(RF-Rt): 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: JUN 23,2008 <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 />