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A lltechpefr�e- ' <br />Compliance without Compromise <br />Spill Bucket Testing Report Form <br />P.O. Box 4208 <br />Sonora CA 95370 <br />Ca: 623541 A-Haz <br />Phone: 209-532-7320 <br />Fax: 209-533-2650 <br />mail@alltechpetro. corn <br />www.alltechpetro.com <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from <br />tests (if applicable), should be provided to the facility ownedoperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Village West Marina Date of Testing: March 21, 2012 <br />Facility Address: 6649 Embarcadero Dr. Stockton CA <br />Facility Contact: Mike Spence Phone: 209-951-1551 <br />Date Local Agency Was Notified of Testing : March 1, 2012 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Alltech Petro Inc, P.O. Box 4208, Sonora CA 95370. (209) 532-7320 <br />Technician Conducting Test: Isaac Anderson <br />Credentials ❑ CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): ICC 8005930 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: 1 -Hour Observed Test <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By <br />Tank Number, Stored <br />Product, etc.) <br />1 Premium 91 <br />2 Diesel <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ In Sump <br />® Direct Bury <br />❑ In Sum <br />❑ Direct Bury <br />❑ In Sump <br />❑ Direct Bury <br />❑ In Sum <br />Wait time between <br />applying vacuum/water <br />and start of test: <br />0 <br />0 <br />0 <br />Test Start Time (T): <br />9:50 <br />9:50 <br />Initial Reading (R,): <br />5" above cap <br />3 1/4" above cap <br />Test End Time (TF): <br />10:50 <br />10:50 <br />Final Reading (RF): <br />5" above cap <br />3 1/4" above cap <br />Test Duration (TF — T,): <br />1.0 Hr. <br />1.0 Hr. <br />Change in Reading (RF -R): <br />0.0 <br />0.0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />1 ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />COI'Y11'1'lents — (include information on repairs made prior to testing, and recommended follow-up for failed <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />/ 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: 3/21/12 <br />