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f <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.fornt and <br /> printouts,from tcvYs(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MATECA ARCO " Date of Testing: 5/16/2013 <br /> Facility Address: 1711 E YOSEMITE AVE City: MANTECA <br /> Facility Contact: MVP Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during testing): STACY RIVERA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials: FFCSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket (lar Tunic 1 87-1 2 3 4 <br /> Number, Slored Proclurl, etc.) <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ®Contained in SUMP Contained in Sum ❑Contained in Surnp ❑ Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 13" <br /> Wait time between applying 5 MIN <br /> vacuum/water-and start of test: <br /> Test Start Time(T,): 11:17 <br /> Initial Readin-(R,): 12" <br /> Test End Time(T,:): 12:17 <br /> Final Reading(R,:): 12" <br /> Test Duration(Tr:-T,): I HR <br /> Change in Reading(RF-R,): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> lest Result: Z Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> ❑ Pass El Fail <br /> Comments- (include information on repairs made prior to testing, and recommerndc cl 1i)llom,-up for failed tests) <br /> TESTED 87-1 BUCKET ONLY DUE TO NEW INSTALL <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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: 5/16/201 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report <br /> 4 of 4 <br />