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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 /> printoutsfrom tests(ifapplicable)should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Valley Pacific Petroleum Date of Testing: 01/19/18 <br /> Facility Address: 930E.Victor Rd.,Lodi,CA 95240 <br /> Facility Contact: Mike Eliason Phone: (209)993-8793 <br /> Date Local Agency Was Notified of Testing: 01/04/18 via email <br /> Name of Local Agency Inspector(fpresent during testing): Cesar Ruvalcaba @ San Joaquin E.H.D. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CGRS, Inc. <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials: E CSLB Contractor E ICC Service Tech. E SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 803616(CSLB Contractor) -- 5254736 (ICC Service Tech.) — 06-1672(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other(Specify) <br /> Test Equipment Used:Tape Measure Equipment Resolution:+or-7116" <br /> Identify Spill Bucket(By Tank T-6 87 Fill T-7 87 Fill <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: E Direct Bury E Direct Bury ❑Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: ill/." 11' <br /> Wait time between applying 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time(T�): 8:10am 8:10am <br /> Initial Reading(R,): 11 'G" 1 P' <br /> Test End Time(Tv): 9:10am 9:10am <br /> Final Reading(RF): 11 y." 11" <br /> Test Duration(Tr—TI): 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0" 0" <br /> Pass/Fail Threshold or Criteria: No Loss No Loss <br /> Test Result: E Pass ❑Fail E 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 /> /hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: I `I— ut, Date: 01/19/18 <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 />