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[iEGEIVED <br /> �ar�aar�PD6 <br /> Spill Bucket Testing Report Form SR, <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures i_ iRMENTAL <br /> Printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local rQgalato�yr agwtsgn�pr�Rr_r�T <br /> I. FACILITY INFORMATION <br /> Facility Name: Gas 4 Less —of Testing:02/18/15 <br /> Facility Address: 3434 Manthey Road Stockton, CA 95206- <br /> Facility Contact: Gilbert Silva (209) 234-7869 <br /> Date Local Agency Was Notified of Testing: 2/12/15 <br /> Name of Local Agency Inspector (dPresent during testing): Michelle Henry <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bei) <br /> Credentials: Q CSLB Contractor Q IGC Service Tech. ❑SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number,Stored Product,etc.) 01 - Re u 02 - Prem <br /> ❑ <br /> Bucket Installation Type: Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑X Contained in Sump Q Contained in Sump (] Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 12.50 in. 12.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. <br /> Test Start Time(Ti): 2:40pm 2:40pm <br /> Initial Reading(R, ): 12.13 in. 11.44 in. <br /> Test End Time(TF). 3:40pm 3:40pm <br /> Final Reading(Fp): 12.13 in. 11.44 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 Q Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Replaced 87 o-ring -Re-Tested & Passed. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the int n co afned in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 02/18/15 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements <br /> may be snore stringent. <br />