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E <br />MAR 16 2016 <br />SWRCB, January 2006 <br />N T <br />N <br />Spill Bucket Testing Report Form W. <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed forr"hC' <br />printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />iWlkN1$_Tz%"Al trolill <br />Facility Name: Mobil/Tesoro 118/16 <br />Facility Address: 401 W. Kettleman Ln. Lodi, CA 95240 <br />Facility Contact: Elizabeth Okupe (209) 368-8787 <br />Date Local Agency Was Notified of Testing: 1/26116 <br />[Name of Local Agency Inspector (if present during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: Myke Briggs <br />Credentialsi: Z CSL13 Contractor Z ICC Service Tech. 0 SWRCB Tank Tester E] Other (Specify) <br />License Number(s): License: 485184 ICC:80331 1 5 -UT <br />Test Method Used: <br />Hydrostatic <br />E] Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:11 /16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - R2gu <br />2 Fill Bucket <br />02 - Prem <br />3 4 <br />I <br />Bucket Installation Type: <br />Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />E] Contained in Sump <br />❑ Direct Bury E] Direct Bury <br />Ej Contained in Sump E] Contained in Sump <br />Bucket Diameter: <br />11.00 in. <br />11.00 in. <br />Bucket Depth: <br />12.50 in. <br />13.50 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />1 min. <br />1 min. <br />Test Start Time IT, <br />9:20arn <br />9:20am <br />Initial Reading (R <br />12.00 in. <br />12.50 in. <br />Test End Time (TF <br />10:20am <br />10:20am <br />Final Reading (P,- <br />12.00 in. <br />12.50 in. <br />Test Duration (TF - T,): <br />1.00 hr, <br />1.00 hr. <br />Change in Reading (RF - R, <br />0.000 in. <br />0.000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />Pass Fail <br />Pass [I Fall <br />D Pass ❑ Fall Pgtso Faalil <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 at/ the information contained In this report Is true, accurateand In full compliance with legal requirements. <br />Technician's <br />Date: 02/18/16 <br />I 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 />