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SWRCB,January 2006 <br /> Spill Bucket Testing Report Forms. {kt:;p � F� , <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: Gas 4 Less Date of Testing: 12/21/15 <br /> Facility Address: 3434 Manthey Road Stockton, CA 95206- <br /> Facility Contact: Jesus Jurado (209) 234-7869 <br /> Date Local Agency Was Notified of Testing: 12/16/15 <br /> Name of Local Agency Inspector (if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Myke Briggs <br /> Credentials: ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8033115-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:11/16 In. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number, Stored Product,etc.) 01 - Regu 02 - Prem <br /> ❑ <br /> Bucket Installation Type: Direct Bury ❑ Direct Bury ❑ Direct Bury E] Direct Bury <br /> ❑X Contained in Sump ❑X Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. <br /> Bucket Depth: 13.00 in. 12.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 10 min. 10 min. <br /> Test Start Time(T,): 1 1:00am 9:00am <br /> Initial Reading(RI ) 12.50 in. 11.00 in. <br /> Test End Time(TF): 12:00pm 10:00am <br /> Final Reading(IAF): 12.50 in. 11.00 in. <br /> Test Duration(TF -T,): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.000 In. 0.000 In. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ❑x Pass ❑ Fail ❑X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Replaced Regular drain gasket- Retest and Passed <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: Date: 12/21/15 <br /> t 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 />