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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(f 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 10/11/12 <br /> Facility Address: 1137 W. Lathrop <br /> Facility Contact: Tyron Phone: 209-824-2760 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C. <br /> Technician Conducting Test: GaryHarris <br /> Credentials: ❑CSLB Contractor x ICC Service Tech. 11 SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment USed:WATER Equipment Resolution:TAP <br /> Identify Spill Bucket(B}, Tank 1 87 FILL 2 91 FILL 3 DIESEL FILL 4 <br /> Number, Stored Product, etc.) i I <br /> Bucket Installation Type: X Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13"1/4 16" 17" <br /> Wait time between applying 5 min 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1:00 pm 1:00 pm 1:00 pm <br /> Initial Reading(Rj): 13"1/4 1619 17" <br /> Test End Time(TF): 2:00 pm 2:00 pm 2:00 pm <br /> Final Reading(RF): 13"1/4 16" 17" <br /> Test Duration(TF—Tj): I hr I hr 1 hr <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or Pass Pass pass <br /> Criteria: <br /> Test Result: x Pass ❑ Fail I 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: <br /> ell- <br /> 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 />