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• ' f 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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Beacon Food&Fuel Date of Testing: 6-27-08 <br /> Facility Address: 2185 E Fremont St, Stockton,CA 95205 <br /> Facility Contact: Phone: <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: HMC-Henderson Maint Co <br /> Technician Conducting Test: Gavin Williams <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 5285969-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Water Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 91 Premium <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> XContained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 15" <br /> Wait time between applying 1 Hr <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): 9:00 <br /> Initial Reading(RI): 13.5" <br /> Test End Time(TF): 10:00 <br /> Final Reading(RF): 13.5" <br /> Test Duration (TF—TI): 1 Hr <br /> Change in Reading(RF-RI): None <br /> Pass/Fail Threshold or Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Replaced 91 Spill Bucket and Tested. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that aU the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature:_ Date:6-27-08 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> —,{.v--ofr;—rt f <br />