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v ' <br /> 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 /> r <br /> Facility Names: National Petroleum Date of Testing 4/20/18 <br /> Facility Address: 713 N.El Dorado <br /> Facility Contact: Gary Phone: 510-361-9396 <br /> 2. TESTING CONTRACTOR INFORMATION Q P R 9 20 <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Jarod Burke ENVIRONMENTAL <br /> Credentials: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify)HF,'. P r117�P:nRTM NT <br /> License Number(s): 00015746 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X flydrostatic Vacuum Other <br /> Test Equipment Used: Fuel Equipment Resolution: <br /> Identify Spill Bucket(By Tank 87 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: 11 <br /> Bucket Depth: 12 <br /> Wait time between applying 10 Min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1:15 pm <br /> Initial Reading(RI): 113/8 <br /> Test End Time(TF): 2:15pm <br /> Final Reading(RF): 113/8 <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-RI): No <br /> Pass/Fail Threshold or Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail Pass ❑Fail Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— G ce, i6a awgc Q Y brr CLe 1//Cx- fu,- Ake— ✓l h <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information conj#tned in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:4/20/18 <br /> 11�1— <br /> t 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 />