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EL <br />MAR 1 82015 <br />S CW <br />Wr <br />OF 7_� A I ­",, <br />Spill Bucket Testing Report Form �-,r%�-jMEWAL <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 />,9E3rV,-7Y§JWFAffj <br />rTTx 0", <br />Facility Name: Mobilrresoro Date of Testing: 02/18/16 <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: 2/12/15 <br />Name of Local Agency Inspector (if present during testing): ArisVeloso <br />Company Name: Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentials': (8] CSLB Contractor [K ICC Service Tech. 0 SWRCB Tank Tester [3 Other (Specif5j <br />License Number(s): License: 485184 ICC:5297793-UT <br />Test Method Used: Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: Measuring Tape Equipment Resolution:1 /16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re <br />2 Fill Bucket 3 4 <br />02 - Prem <br />Bucket Installation Type: <br />Direct Bury <br />C] Contained in Sump <br />Direct Bury n Direct Bury n Direct Bury <br />❑ Contained in Sump [3 Contained in Sump E] Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />13.25 in. <br />13.00 in, <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />5 min. <br />Test Start Time IT, <br />10:44am--- <br />9:06am <br />Reading (R <br />13,00 in. <br />12.38 in. — - - ---_-_ - - <br />-Initial <br />Test End Time (TF <br />11:44am— <br />10:06am <br />Reading (FF <br />13.00 in. <br />12.38 in. <br />-Final <br />Duration (TF - T,): <br />1.00 hr. <br />1.00 hr. <br />-Test <br />in Reading (RF - R, <br />0.000 in. <br />0,000 in. <br />-Change <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />Pass E] Fail <br />E) Pass C] Fail 0 Pass ❑ Fail El Pass Cj Fail <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the 1n6yzat!V co4talned In this report Is true, accurateand In full compliance with legal requirements. <br />Technician's <br />Date: 02/18115 <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 />