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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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: BOYETT-VALERO Date of Testing: 8-28-14 <br /> Facility Address: 1137 W. LATHROP <br /> Facility Contact: RICK Phone: (209)824-2760 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rfpresent during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LC SERVICES <br /> Technician Conducting Test: JOSE OCHOA <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(4y Tank 1 - 87 2- 91 3- DIESEL 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: U Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 16" 16" 15 %Z" <br /> Wait time between applying 15 MINUTES 15 MINUTES 15 MINUTES <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): PaMR 4 q:o% r 1:23 PM 1:23 PM <br /> Initial Reading(R,): 16" 16" 15 %2" <br /> Test End Time(TF): •.�9: 2:23 PM 2:23 PM <br /> Final Reading(RF): 0" 16" 1.5 ''/z" <br /> Test Duration(TF—Ti): I HR I HR I HR <br /> Change in Reading(RF-R,): 16" 0" 0" <br /> Pass/Fail Threshold or NO DROP NO DROP NO DROP <br /> Criteria: <br /> Test Result: ❑ Pass X Fail X Pass ❑Fail X Pass ❑Fail ❑ Pass ❑ Fail <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 /> 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: 8-28-14 i <br /> ' State laws and reg ions do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. , <br />