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P.O.Box 4208 <br /> Sonora CA 95370 <br /> Alitech,Petr - Ca:209-53 -7320 <br /> Phone:209-532-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> wvvw.alltechpetro.com <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 printouts from <br /> 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: Village West Marina Date of Testing: Friday, March 25, 2011 <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 : Thursday, March <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 Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By 1 Premium 91 2 Diesel 3 4 <br /> Tank Number, Stored <br /> Product, etc.) <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑ In Sump In Sump In Sum ❑ In Sum <br /> Wait time between <br /> applying vacuum/water 0 0 0 <br /> and start of test: <br /> Test Start Time (T): 9:15 9:15 <br /> Initial Reading (R,): Top of adapter Top of adapter <br /> Test End Time (TF): 10:15 10:15 <br /> Final Reading (RF): Top of adapter Top of adapter <br /> Test Duration (TF—T): 1.0 Hr. 1.0 Hr. <br /> Change in Reading (RF-R): 0.0 0.0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail I ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br /> 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: Date: 3/23/11 <br />