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. AE:CE1VLJ <br /> J U L 0 3 SwI?CB,January 2006 <br /> ENVIRONMENTAL <br /> Spill Bucket Testing Report Form I - ' nr,7P/\RTMENT <br /> This form/s intended for use by contractors performing annual testing of UST spit/containment structures. The completed form and printouts from <br /> tests(Yapplicable),should be provided to the facility owner/operator forsubmrtta/to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: West Valley Auto Service Chevron Date of Testing: 6-28-2017 <br /> Facility Address: 36979 Fremont Blvd Fremont <br /> Facility contact: Site Manager Phone: 209- <br /> Name of Local Agency Inspector(//present during testing) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Pinnacle Fuel Compliance Services, Inc. <br /> Technician Conducting Test: Aneil Chand <br /> credentials: ®CSLB Contractor ®ICC Service Tech. ®SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): ICC#5119959-UT SWRCB#90-1262 CSLB#894932 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure, Stop Watch Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc. Super Regular Diesel <br /> Bucket Installation Type: Sump Sump Sump <br /> Direct Bu /Sum <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying 5mins 5mins 5mins <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): <br /> Initial Reading(Ri): 60mins 60mins 60mins <br /> Test End Time(TF): 11" 11" 11" <br /> Final Reading(RF): Omins Omins Omins <br /> Test Duration(TF-T,): 60mins 60mins 60mins <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0"-60mins 0"-60mins 0"-60mins <br /> Test Result: Pass/Fail PASS PASS PASS <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 /> l 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: 6/28/2017 <br /> i State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more <br /> stringent. <br />