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JIJL-14-2011 10:55 Service Station Systems 408 938 8888 P.02 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractorspeAorming annual testing of UST spill containment structores. The completed form and <br /> printouts from tests(if app%moble),should be provided to the facility owneNoparator for submittal to the/oral regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Kadlity Na me: Safeulla 2707 Date of Testing:6/20/11 <br /> Facility Address: 6425 N. Pacific Ave. Stockton, CA 96207- <br /> Facility Contac: Julia Pollick (209)472-8600 <br /> Date Local Agency Was Notified of Testing: 6/6/11 <br /> Name of Loral Agency Inspector (If present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> company Name:Service Station Systems <br /> Technician Conducting Test: Bryan Lundien <br /> Credentialsi: ®CSLB Contractor ® ICC Service Tech. ❑ SwRC8 Tank Tester [] Other(Spad/Y) <br /> License Number(s): License;455184 ICC:8001468-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ©Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution://16 in. <br /> r I r. 111 11,v .1 il W11"', .�a� . ..:..,.'v,v f I...::... „'-.i:.n V . ..R:. .rv::s iJ <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 13 Fill Bucket 4 <br /> Number,SloredProduct,etc.) 01 Re u 02 Prem 03 Diesel <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury Cl Direct Bury <br /> Bucket Installation Type: <br /> (R,J Contained in Sump ©Contained in Sump [RJ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter. 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 15.50 In. 15.50 in. 15.50 in, <br /> wait time between applying 5 min. 5 min. 5 min. <br /> vacuumhveter and start of test; <br /> Test Start Time(T,): 1:00pm 1:00pm 1:00pm <br /> Initial Reading(R ): 15.000 in. 15.000 in. 15.000 in. <br /> Test End Time(Tr:): 2:00pm 2:00pm 2:00pm <br /> in Reading(r ): 15.000 in. 15.000 in. 15.000 in. <br /> Test Duration(TF•T,): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. 0.0000 in. 0,0000 in. <br /> PassrKall Threshold or Criteria ZERO LOSS ZEROLOSS ZERO LOSS <br /> pdnlr., i ; ','.w1 ` i n `'"x�e'€'ib7v.',ijhM'.,ty,•'a' 'fIYP3S8 Cj Fatk.: <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 Slgnature:f Data*6/20/11 <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 />