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SRCa�2006 <br /> Spill Bucket Testing Report Form ENVIR(7�NTA� <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment structure+st.�''dA "mfma <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY_ INFORMATION <br /> Facility Name: CRUISER Date of Testing: 8/19/15 <br /> Facility Address: 1137 W LAPTHROP MANTECA CA <br /> Facility Contact: RICK Phone: 209-824-2760 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): ELENA MANZO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: GaryHarris <br /> Credentials': ❑CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) I <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic E Vacuum D Other <br /> Test Equipment Used:WATER Equipment Resolution:TAP <br /> Identify Spill Bucket (B.y Tank 1 87 FILL 2 91 FILL 3 DIESE FILL 4 87 FILL <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury ❑Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump XContained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 169$1/2$' 17" 16"1/2" 16"1/2" <br /> I <br /> Wait time between applying 30-MIN 30-MIN 30-MIN 30-MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10.10AM 10.10AM 10.10AM 1.35PM <br /> Initial Reading(RO: 14"1/2" 14"1/2" 14' 14"1/4" <br /> Fest End Time(TF): 11.10AM I LIOAM I LIOAM 2.35PM <br /> Final Reading(RF): 10"1/2" 14"1/2" 14" 14"1/4" <br /> Test Duration(TF-T,): 1-HR I-H R 1-HR 1-HR <br /> Change in Reading(RF-Rj): YES NONE_. NONE NONE <br /> Pass/Fail Threshold or FAIL PASS _ PASS PASS <br /> Criteria: <br /> Test Result: Pass X_Fail I X Pass O Fail X Pass 0 Fail X Pass 0 Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 87-SPILL BUCKET FAIL HAD REPLACED DRAIN VALVE O RING <br /> AND SPILL BUCKET SEAL ALSO ADPATER 'A GASKET <br /> AND RETEST <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this re , t is true,accurate,and infull compliance with legal requirements. <br /> Technician's Signature: Date: e-/Ci -/S <br /> ' State laws and regulations do not curre tly require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />