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Spill Bucket Testing Report Form <br />rliis form is intended for use by contractors performing annual testing of UST spol containment structettcs. The completed form and printouts from tests (if applicable), should be <br />provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. Facility Information <br />Cusmmer <br />Job Location <br />Work Order <br />124679 <br />7/11 if 19976 <br />1399 North Main Street <br />Manteca, Ca. 956336 <br />209-239-3252 <br />7/11 919976 <br />1399 North Main Street <br />Manteca, Ca. 956336 <br />209-239-3252 <br />Contact <br />site No. <br />Jay Stetnley <br />19976 <br />Date Local ,Agency was notified of testing: <br />Name of Local Agency Inspector (if present during testing) <br />2. Testing Contractor Information <br />Company Name: <br />Sacramento Equipment Maintenance Company, Inc. <br />Technician Conducting Test: <br />Jim Hutchins <br />CredEntials(l ): <br />CSLB Contractor <br />ICC Service Tech <br />S1.VR B 'rank tester <br />Other (specify): <br />License Number(s): <br />502377 <br />5250194 -UT <br />3. Spitl Bucket Testing Information <br />Fest Method Used: <br />Hvdrostatic <br />Vacuum <br />Other <br />Test Equipment Used: <br />WaterMfeasure Tape <br />Equipment Resolution: <br />Identify Spill Bucket (by Tan): Number, Stored <br />Product, etc.) <br />1 - T5 (91) <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />OPW <br />Bucket Diameter: <br />1 V, <br />Bucket Depth: <br />12" <br />Wait time between applying vacuum/watcr and start <br />of test: <br />.50 hour <br />Test Start Time (Tl) <br />11:00 <br />Initial Reading (RI) <br />3 1/4 from top of cap <br />Test End Time (Tf) <br />12:00 <br />Final Reading (Rf) <br />3 1/4 <br />"Ibst Duration (T1 - "I'i): <br />one hour <br />Change in Reading (Rf - Rl ) <br />Pass/Fail Threshold or Crites: <br />Tact ResultsPASS <br />Dail <br />Pasq <br />Dail <br />Pass <br />Dail <br />Pass <br />Fail <br />Comments: (includes 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 ccrtily that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />`I <br />Date: <br />2-02-07 <br />( I ) State laws and regulations do not curreuAyWequire testing to be performed by a qualified contractor. However, local requirements may be more <br />stringent. g/c/OOOOf/state/spillbucket.wpd <br />