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SWRCB,January 2006 <br /> Spill Bucket Testing Report For <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: KWIK SERVE Date of Testing: 10-20-09 <br /> Facility Address: 950 W. 11TH ST,TRACY,CA 95376 <br /> Facility Contact: PATEL I Phone: 209-832-1810 <br /> Date Local Agency Was Notified of Testing: I0-12-09 <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-SERVICE STATION TESTING <br /> Technician Conducting Test: HEATH MCEVER <br /> Credentials': ❑CSLB Contractor D4C Service Tech. WRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 04-1677 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: WATER Equipment Resolution:INCHES <br /> Identify Spill Bucket(By Tank 187 291 3 DSL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in S2mp ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 11.5 13.25 15.75 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0918 0917 0918 <br /> Initial Reading(Rj): 10.25 12.5 14.75 <br /> Test End Time(TF): 1018 1017 1018 <br /> Final Reading(RF): 10.25 12.5 14.75 <br /> Test Duration(TF—T j): 1 HR 1 HR I HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: ass ❑Fail ass ❑Fait ass 0 Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIJNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informatio ntained in this report is true,accurate,and in full compliance with legal requirements. <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 /> maxi ha mnra e/rinrtant <br />