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0 0 <br /> SV%RCB,January 2006 <br /> Spill 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 ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tracy Blvd Shell &Mini Mart Date of Testing:01/25/18 <br /> Facility Address: 3725 N. Trac Blvd. Tracy, CA 95376 <br /> Facility Contact: Tanya Moore (209)835-7608 <br /> Date Local Agency Was Notified of Testing: 12/27/17 <br /> Name of Local Agency Inspector (if present during testing): Betty Ho <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Kris Bell <br /> Credentials,: [8] CSLB Contractor [K ICC Service Tech. E] SWRCI3 Tank Tester E] Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El vacuum 0 Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tanki 1 Fill Bucket 2 Fill I I Fill Bucket 4 Fill Bucket <br /> Number, Stored Product,etc.) I'l <br /> 01 - Re 02. Plus 03-Prem 04- Diesel <br /> Bucket Installation Type: ❑ <br /> Direct Bury ❑ Direct Bury M Direct Bury E] Direct Bury <br /> Contained in Sump Contained in Sump 0 Contained in Sump Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 15.00 in. 13.50 in. 14.00 in. <br /> Wait time between applying 10 min. 10 min. 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time(TI 9:39am 9:37am 9:40am 9:41 am <br /> Initial Reading(Ri 13.750 in. 13.250 in. 12.500 in. 12.750 in. <br /> Test End Time(TF 10:39am 10:37am 10:40am-_ 10:41am <br /> Final Reading(t� 13.750 in. 13.250 in. 12.500 in. 12.750 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R, 0.0000 in. 0,0000 in, 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: M Pass E]Fail [K Pass E] Fail I (K Pass E] Fail 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 certify that all the info n cordained in this report is true,accurateand in full compliance with legal requirements. <br /> Technician's Signature: Date..01/25/18 <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 />