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S W RC B,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 agcncy- <br /> 1. FACILITY INFORMATION <br /> Facility Names: National Petroleum Date of Testing: 6/1/2018 <br /> Facility Address: 713 N El Dorado St Stockton Ca 95205 <br /> Facility Contact: Gary Vaghasia Phone: 510-361-9396 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: <br /> Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specift) <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(By Tank 1 91 2 3 4 <br /> Number, Stored Product, etc.) _ <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 14" <br /> Bucket Depth: 14" <br /> Wait time between applying 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 12:00 <br /> Initial Reading(Rj): 12" <br /> Test End Time(TF): 1:00 <br /> Final Reading(RF): 12" <br /> Test Duration(TF—Tj): 1 hr <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail Pass ❑Fail Pass ❑Fail ❑ Pass ❑Fail <br /> Coninlents — (include information on repairs made prior to testing, and r•ec•onunended follotit�-tip 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 regt irements. <br /> Technician's Sig nature:4 ez//zt{ Date: <br /> _(,p . I I �)_ <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 />