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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 ownerfoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gas 4 Less Dale of Testing:2/27/14 <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: 2/13/14 <br /> Name of Local Agency Inspector (if present during testing): Thuy Tran <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentials: © CSLB Contractor ❑x ICC 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: ❑X Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:)/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 /> El Bury ElDirect Bury E] Direct Bury E] Direct Bury <br /> Bucket Installation Type: <br /> ❑X Contained in Sump Q Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. <br /> Bucket Depth: 13.00 in. 13.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test. 5 min. 5 min. <br /> Test Start Time(Ti): 9:14am 9:14am <br /> Initial Reading(R ): 13.000 in. 12.000 in. <br /> Test End Time(TF): 10:14am 10:14am <br /> Final Reading(F�-): 13.000 in. 12.000 in. <br /> Test Duration(TF-T i): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.0000 In. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ❑x Pass ❑ Fail I ❑X 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 /> 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: �2 Date: 2/27/14 <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 />