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11 V � 4p RECEIVED <br />fiNVIROWENTAL <br />Spill Bucket Testing Report Form I4F,6 I TU nC'04PTMC:KiT <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 (!f applicable), should be provided to <br />the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Tracy Blvd Shell & Mini Mart Date of Testing: 01/27/16 <br />Facility Address: 3725 N. Tracy Blvd. Tracy, CA 95376 <br />Facility contact: Tanya Moore (209) 835-7608 <br />Date Local Agency Was Notified of Testing: 12/30/15 <br />Name of Local Agency Inspector (if present during testing): Victoria McCartney <br />2_ TESTING CONTRACTOR INFORMATION <br />company Name:Service Station Systems <br />Technician Conducting Test: loris Bell <br />Credentialsi : ® CSLB Contractor Q ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License; 485184 ICC:5297793-UT <br />3. SPII_I RIIMICT TFRTINr. INFnRMATlinm <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />[ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resoiution:1/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stoned Product, etc.) <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />02 - Plus <br />3 Fill Bucket <br />03 - Prem <br />4 Fill Bucket <br />04 - Diesel <br />Bucket Installation Type: <br />E]Direct Bury <br />® Contained In Sump <br />E]Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />Bucket Diameter. <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />1 0 min. <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time (Ti ); <br />9:20am <br />9:20am <br />9:20am <br />9:20am <br />Initial Reading (R, ): <br />13.75 in. <br />13.13 in. <br />13.50 in. <br />12.31 in. <br />Test End Time (TF ): <br />10:20am <br />10:20am <br />10:20am <br />10:20am <br />Final Reading (RF ): <br />13.75 in. <br />13.13 in. <br />13.50 in. <br />12.31 in. <br />Test Duration (TF - T 1): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - Rj <br />0.000 in. <br />0.000 in. <br />0.000 in. <br />0.000 in. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Resul# <br />Past Q Fail, f <br />®F'as ❑,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 /nom cogita/ned in this report /s true, accurate,and /n full compliance with legal requirements. <br />Technician's <br />Data: 01/27/16 <br />t 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 />