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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 /> 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: Wine Country 76 Date of Testing: 10/22/2014 <br /> Facility Address: 1111 E.Kettleman Ln.,Lodi,CA 95240 <br /> Facility Contact: Sonnie Phone: (40 <br /> Date Local Agency Was Notified of Testing: "0 <br /> Name of Local Agency Inspector(ifpresent during testing) Michelle Henry <br /> NOV 2 6 2014 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Zqf" <br /> Spill Bucket (By Tank 1 Tl: 87 Fill 2 T2: 91 Fill 3 T3: Diesel Fill 4 <br /> , Stored Product, etc. <br /> x Direct Bury x Direct Bury x Direct Bury xDirect Bury <br /> Installation Type: ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum 11 Contained in Sum <br /> Diameter: 12" 12" 12"Depth: 14" 14'/d' 13 '/d'e between applying 1 min. 1 min. 1 min./water and start of test:art Time(Tj): 9:30 a.m. 9:30 a.m. 9:30 a.m.eading(Rj): 12 7/8" 13 1/8" 11 '/d' <br /> Test End Time(TF): 10:30a.m. 10:30a.m. 10:30 a.m. <br /> Final Reading(RF): 12 7/8" 13 1/8" 11 '/1' <br /> Test Duration(TF—Tj): 1 hr lhr 1 hr <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass ❑Fail x Pass ❑Fail x 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 /> gn ttya! P � Jf�/ <br /> Technician's Si a �s c Date 10/22/2014 <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 />