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• 0 0 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 I Date of Testing: 05-29-09 <br /> Facility Address: 515 W. 1 Vh Street, Tracy CA 95376 <br /> Facility Contact. Abdul [ Phone: 510-366-9924 <br /> Date Local Agency Was Notified of Testing: 05-26-09 <br /> Name of Local Agency Inspector(ifpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials]: X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank T1: 87 Fill T2:-Diesel Fill Fill 91 Fill <br /> Number, Stored Product, etc. <br /> X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> Bucket Installation Type: Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 1219 <br /> Bucket Depth: 141/4" 15 V2" 15" <br /> Wait time between applying linin. linin. linin. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9.24a.m 9:25a.m 9:39a.m <br /> Initial Reading(Ri): 12%11 13 7/8'9 13%11 <br /> Test End Time(TF): 10:32a.m 10:31a.m 10:55a.M <br /> Final Reading(RF): 12%11 137/811 13'/299 <br /> Test Duration(TF—Ti): 1hr.min. 1hr.6min. lhr. 16min. <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/1611 <br /> Test Result: X Pass Fail 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 info contained in tills report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature <br /> — Date:05-29-09 <br /> 47 <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 />