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SWRCB,January 2006 <br /> ill Bucket Testing <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 /> 1. FACILITY INFORMATION <br /> Facility Name: Mobil/Tesoro Date of Testing:02/23/18 <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: 1/25/18 <br /> Name of Local Agency Inspector (if present during testing): Cesar RuValcaba <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentials: ®CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 iCC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number,Stored Product,etc.) ____2L-Reg u 02-Prem <br /> Bucket Installation Type: [@ Direct Bury ®Direct Bury E] Direct Bury E] Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11.50 In. 11.50 in. <br /> Bucket Depth: 13.00 in. 13.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. <br /> Test Start Time(T,}: 9:50am 9:50am <br /> Initial Reading(R, ): 11.000 in. 12.500 in. <br /> Test End Time(TF j: 10:50am 10:50am <br /> Final Reading(RF): 11.000 in. 12.500 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-RI}: 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ®Pass ❑Fail ®Pass ❑Fad ❑ Pass 0 Fail ❑Pass ❑Feil <br /> Comments: Include information on repairs made prior to testing,and recommended follow-up for failed tests. <br /> i <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the;linforRiallon contained in this report is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: __ Date.: 02/23/18 <br /> i <br /> 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 /> { <br /> r <br />