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I I " 0 0 RECEIVED <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 l <br /> 1. FACILITY INFORMATION HEALTH DEPARTMENT <br /> Facility Name: ARCO AMPM Date of Testing: 1/15/2014 <br /> Facility Address: 2908 W BENJAMIN HOLT City: STOCKTON <br /> Facility Contact: LAWRANCE Phone: 209-993-7825 <br /> Date Local Agency Was Notified of Testing: Friday,December 06,2013 <br /> Name of Local Agency Inspector(f present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: RHOME DESBIENS <br /> Credentials': ®CSLB Contractor ®ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:RULER Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 2 87-2 3 91 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> ®Contained in Sump Contained in Sump Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11" 11" 1199 <br /> Bucket Depth: 12.5" 12.5" 12.5" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:56 11:56 11:56 <br /> Initial Reading(Rj): 11.75" 11.75" 11.75" <br /> Test End Time(TF): 12:56 12:56 12:56 <br /> Final Reading(RF): 11.75" 11.75" 11.75" <br /> Test Duration(TF—Tj): 1 HR IHR IHR <br /> Change in Reading(RF—Rj): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test°Result: :, Pass, ❑]fail '�- :Pass l Fail Z Fass, ,❑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 Signature: �/ /-`'" Date: 1/15/2014 <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 />