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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 owneNoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Manteca Cruisers Date of Testing:08/29/18 <br /> Facility Address: 1137 W. Lathrop Rd. Manteca, CA 95336- <br /> Facility Contact: Unknown (209)824-2760 <br /> Date Local Agency Was Notified of Testing: 8/15/18 <br /> Name of Local Agency Inspector (if present during testing): Zuna Barker <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Brian MCPheely <br /> Credentials: © CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8822062 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 In. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket7— <br /> Number, <br /> Stored Product,etc.) 01 -Re u 02.-Prem 03 - Diesel <br /> Bucket Installation Type: E)Direct Bury E] Direct Bury C] Direct Bury ❑ Direct Bury <br /> ❑X Contained in Sump ❑X Contained in Sump © Contained in Sump ❑Contained In Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 15.50 in. 16.25 in. 15.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. 5 min. <br /> Test Start Time(T, ): 3:00pm 3:00pm 3:00pm <br /> Initial Reading(R, ): 14.000 in. 16.250 in. 13.000 in. <br /> Test End Time(TF): 4:00pm 4:00pm 4:00pm <br /> Final Reading(F�): 14.000 in. 16.250 in. 13.000 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 /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: ® Pass [3 Fail ® Pass ❑ Fail ® Pass ❑ Fail E] Pass E] Faii <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 /> 1 hereby certify that all�the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> .`1 <br /> lL <br /> Technician's Signature: Date:08/29/18 <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 />