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JUL-01-2011 08:30 Service Station Systems 408 938 8888 P.02 <br /> SWRCB,January 2096 <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: Shell/Tesoro Date of Testing-5/31/11 <br /> Facility Address: 2448 W. Kettleman Ln, Lodi, CA 95242 <br /> Facility Contact: Mary Morgan (209) 369-3124 <br /> Date Local Agency Was Notified of Testing: 5/17/11 <br /> Name of Local Agency Inspector (ifpresen!during tasting): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:$ervice Station Systems <br /> Technician Conducting Test; Bryan Lundeen <br /> Credentlalsi: (] C,9L5 Contractor [,Z ICC Service Tech. ❑ SWRCS Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 1CC:8001458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: © Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution;1/16 in. <br /> Identify Splli Bucket (Sy Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number, Stored Product, etc.) 01 Re u 02 Prem 03 Diesel <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> Q Contained in Sump Contained in Sump © Contained In Sump E] Contained in Sump <br /> Bucket Diameter: 12.00 in, 12.00 in. 12.00 in. <br /> Bucket Depth: 12.50 in. 11.50 in. 14.50 in. <br /> wait time between applying <br /> vacuum/water and start of test: 5 min, 5 min. 5 min. <br /> Test Start Time(T,): 10:15am 10,15am 10:15am <br /> Initial Reading(R, ): 11.875 in. 11,125 in, 14.250 in. <br /> Test End Time(TF): 11:15am 1115am 11:15am <br /> Final Reading(%): 11.875 in. 11.125 in. 14.250 in. <br /> Test Du ration(TF -TI): 1.00 hr. 1.00 hr. 1.00 hr. <br /> f-H . .;'Plc q;nn IG_-P.\ n nnnn in =..i.m <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: LA Pass ❑ Fait ® pass ❑ Fail [ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Replaced 91 Fill Cap, tested and passed <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the Information contained/n this report/s true,accurate,and/n full compliance with legal requ/rements. <br /> Technician's Signature: Date; 5131/11 <br /> 1 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 />