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1 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: YRC 813 Date of Testing: 2/6/2017 <br />Facility Address: 1535 E PESCADERO AVE, TRACY, CA 95304 <br />Facility Contact: CHRIS ROY Phone: 209-993-7946 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): victoria !-^ <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Steve Willems <br />Credentialsl: r CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester r Other (Specify) F- <br />License Number(s): A <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By* Fv Hydrostatic i- Vacuum r Other <br />Test Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box # Tank Soap Tank <br />OTHER - Fill 1 - Direct - <br />Grade level <br />Spill Box # Tank waste oil <br />new rack WASTE OIL - Fill <br />1 - Direct - Grade level <br />Spill Box # Tank anti freeze <br />ANTIFREEZE - Fill 1 - <br />Direct - Grade level <br />Spill Box # Tank gear oil <br />GEAR OIL - Fill I - Direct - <br />Grade level <br />Bucket Installation Type: <br />IT Direct Bury <br />r Contained in Sump <br />IT Direct Bury <br />r Contained in Sump <br />F Direct Bury <br />f Contained in Sump <br />G Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />12.00 <br />12.00 <br />Bucket Depth: <br />22.25 <br />20.75 <br />18.50 <br />21.50 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />5 min <br />5 min <br />Test Start Time (TI): <br />10:27:00 <br />12:03:00 <br />11:31:00 <br />11:31:00 <br />Initial Reading (RI): <br />21.75 in. H2O <br />20.00 in. H2O <br />17.50 in. 1420 <br />20.00 in. H2O <br />Test End Time(TF): <br />11:27:00 <br />13:03:00 <br />12:31:00 <br />12:31:00 <br />Final Reading (RF): <br />21.75 in. H2O <br />20.00 in. H2O <br />17.50 in. H2O <br />20.00 in. H2O <br />Test Duration(TF-TI): <br />1 hr <br />I hr <br />1 hr <br />1 hr <br />Change in Reading (RF -RI) : <br />0.00 in. H2O <br />0.00 in H2O <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/-0.00 <br />+/-0.00 <br />Test Result: <br />Pass <br />Pass <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, and recommended.follow-up forfhded 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: <br />Date: 2/6/2017 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2329993 <br />