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0 SWRCB,January 2006 <br /> it 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kwik Sery Date of Testing: 9-2-10 <br /> Facility Address: 950 W 11 th Tracy,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Michell Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Henderson Maintenance Company <br /> Technician Conducting Test: Gavin Williams <br /> Credentials': [X] CSLB Contractor [X]ICC Service Tech- 11 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): CSLB: 856771 ICC:8016288 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 11 Vacuum 11 Other <br /> Test Equipment Used: Water Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1-Diesel 2-87 3-91 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury 0 Direct Bury <br /> 0 Contained in Sump 0 Contamed m Sump 0 Contamed m Sump El Contained in Sump <br /> Bucket Diameter: III, III, III, <br /> Bucket Depth: 15" 14" 14" <br /> Wait time between applying I hr I hr I hr <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10 10 10 <br /> Initial Reading W: 14" 12" 12" <br /> Test End Time(TF): 11 I I 11 <br /> Final Reading(RF): 14" 12" 12" <br /> Test Duration(TF—T): I hr I hr I hr <br /> Change in Reading(RF-R0: 0 0 0 <br /> Pass/Fail Threshold or Pass Pass Pass <br /> Criteria: <br /> Test Result: X Pass []Fail X Pass []Fail X Pass El Fail 11 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 cafify that all the information commined in this rqwt is true,accurate,and infufl compliance nft legal requirentents. <br /> Technician's Signature: Date: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />