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%/ SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is inlendedfor 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/operatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: YRC 813 1FDate 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 />` '•- - <br />Technician Conducting Test: Steve Willems <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />Credentials: r CSLBContractor W ICCServiceTech. <br />i- SWRCBTankTester r other (Specify)ENVORONMEW1.- - - <br />LicenseNumber(s): A <br />C-ER""RT I' <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r Hydrostatic (— 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 motor oil <br />MOTOR OIL - Fill 1 - Direct <br />- Grade level <br />Spill Box # Tank waste oil <br />tank pad WASTE OIL - Fill <br />1 - Direct - Grade level <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />ro Direct Bury <br />r Contained in Sump <br />f: Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />f- Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />18.00 <br />15.50 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />min <br />min <br />Test Start Time (Tt): <br />11:31:00 <br />11:31:00 <br />Initial Reading (1117 <br />17.00 m.1120 <br />14.75 in. H2O <br />Test End Time(TF): <br />12:31:00 <br />12:31.00 <br />Final Reading (RF): <br />17.00 in. H2O <br />14.75 in. H2O <br />Test Duration(TF-T1): <br />1 hr <br />1 hr <br />Change in Reading (RF—Rt) : <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />Test Result: <br />Pass <br />Pass <br />Comments -(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTMCA71ION 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: OJQ�1` <br />Date: 2/62017 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements maybe more stringent. <br />WO: 2329893 <br />