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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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SB Gas and Market Date of Testing: 06/04/2013 <br /> Facility Address: 515 W. 11 th ST.Tracy,Ca.95376 <br /> Facility Contact: Abinash Sharma Phone: (209)834-8838 <br /> Date Local Agency Was Notified of Testing: / <br /> Name of Local Agency Inspector(rf present during testing): Aris Cacapit <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. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> P <br /> od Used: xHydrostatic ❑Vacuum ❑Other <br /> pment Used: Standard Tape Measure Equipment Resolution: <br /> pill Bucket(By Tank 1 T1: 87 Fill 2 T2: Diesel Fill 3 T3: 91 Fill 4 T4: <br /> Stored Product, etc. <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 141/4" 151/2" 15" <br /> Wait time between applying 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 09:11 a.m. 09:12 a.m. 09:10 a.m. <br /> Initial Reading(Ri): 13 3/4" 14 7/8" 14 3/8" <br /> Test End Time(TF): 10:11 a.m. 10 :12 a.m. 10:10 a.m. <br /> Final Reading(RF): 13 3/4" 14 7/8" 14 3/8" <br /> Test Duration(TF—Ti): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <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 information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signatur Date 06/04/2013 <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 />