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0 <br /> R _ A; <br /> SWRCB,Janus <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The comple= <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulato <br /> 1. FACILITY INFORMATION <br /> Facility Name: Unocal Date of Testing:12/10/15 <br /> Facility Address: 2701 West March Lane Stockton, CA 95219 <br /> Facility Contact: Darren Eppler (209)473-7337 <br /> Date Local Agency Was Notified of Testing: 11/12/15 <br /> Name of Local Agency Inspector (if present during testing): Fatinah Zareef <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentialsi: [M CSLB Contractor [K ICC Service Tech, [3 SWRCB Tank Tester F] Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑vacuum 0 Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:)/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number,Stored Product,etc.) 01 -Re2u 02-Prem 03-Diesel <br /> Bucket Installation Type: 0 Direct Bury M Direct Bury Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained In Sump ❑Contained in Sump C]Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 12.00 in. 12.00 in. 13.25 in. <br /> Wait time between applying 10 min. 10 min. 10 min. <br /> vacuumtwater and start of test: <br /> Test Start Time(TI 9:56am 9:56am 9:56am <br /> Initial Reading(R 12.00 in. 11.44 in. 12.50 in. <br /> Test End Time(TF 10:56am 10:56am 10:56am <br /> Final Reading(FF 12.00 in. 11.44 in. 12.50 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr, 1.00 hr. <br /> Change in Reading(RF-R, 0.000 in. 0.000 in. 0.000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: Q Pass [3 Fail 0 Pass 0 Fail 1@ Pass E]Fall ❑Pass f-I 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 coatained In this report is true,accurateand in full compliance with legal requirements. <br /> Technician's Signature: Date; 12/10/15 <br /> 1 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 />