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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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SB Gas&Mart Date of Testing:05-17-10 <br /> Facility Address: 515 West 11'h St. Tracy,CA. <br /> Facility Contact:Abdul — Phone: (209)832-8838 <br /> L Date Local Agency Was Notified of Testing: 05/06/10 <br /> Name of Local Agency Inspector(ii(present during testing):Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> _Co!jjpan,y Name: Reliable Petroleum Services Inc. <br /> Technician <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Spec6) <br /> 9 License Number(s):883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: R—H—ydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Standard Equipment Resolution: <br /> Identify Spill Bucket(By—Tank TI: 87 T2: Diesel T3: 91 <br /> T3* 91 <br /> 1 Number,Stored Product, etc.) FILL FILL <br /> Direct B <br /> X Direct Bury X Direct Bury Bury <br /> Bucket Installation Type: C Sump 0 C X Direct Bury 0 Direct Bury <br /> C]Contained <br /> 0 Contained in Sum 0 Contained in Sum 0 Contained in Sum 0 Contained in Q, <br /> Bucket Diameter: 1299 1211 12" <br /> Bucket Depth: 141/411 15'14" 14%4" <br /> Wait time between applying 1 min <br /> -vacuum/water and start of test: I min 1 min <br /> Test Start Time(Tj): 9:26 a.m. 9:25 a.m. 9:26 a.m. <br /> Initial Reading(Rj): 1399 1315/1611 131KII <br /> Test End Time(TF): 10:41 a.m. 10:41 a.m. 10:41 a.m. <br /> Final Reading(RF): 1399 13 15/16" 13Y211 <br /> Test Duration(TF- <br /> Ti): thr 15min <br /> 1hr 16min 1hr 15min <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" 1/16" 1/1611 <br /> Ljesl Result: X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail <br /> 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended 1011ow-upfor 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:5-17-10 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However, <br /> may be more stringent. local requirements <br />