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10 0 <br />RECEIVEC: <br />SMC0Rj5 <br />Spill Bucket Testing Report Form FE@u2Y7 <br />This form is intended for use by contractors perform'annual facility <br />Thl, <br />g of UST spill containment structures. <br />ty ca r,4 <br />gu, 10(WMENTAL <br />printouts from tests (if applicable), should be provided to the owner/operator for submittal to the to gwocai n Wrq fil=wr <br />pff7w7nomorys-Tux nm mo, <br />Facility Name: Tracy Blvd Shell & Mini Mart Date of Testing: 01/29/15 <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: 1/13/15 <br />Name of Local Agency Inspector (if present during testing),, Michelle Henry <br />Company Name: Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentialsi: lN CSLB Contractor [E ICC Service Tech. [] SWRCB Tank Tester E] Other (Specify) <br />License Number(s): License: 485184 ICC:5297793-UT <br />Test Method Used:j <br />- - ------- -- <br />Hydrostatic <br />❑ vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />I Equipment Resolution:1/16 in. <br />...... <br />Identify Spill Bucket (By Tank <br />Identify <br />Number, Stored Product, etc.) <br />ill Bucket <br />01 - Re <br />-8 cket <br />FR u <br />02 - Plus <br />.. ... . <br />3 Fill Bucket <br />03 - Prem <br />4 Fill Bucket <br />04 - Diesel <br />- fBucket Installation Type: <br />C] Direct Bury <br />Contained in Sump <br />C] Direct Bury <br />Contained in Sump <br />0 Direct Bury <br />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 />13.50 in. <br />13.50 in. <br />13.00 in. <br />13.00 In. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />5 min. <br />5 min. <br />5 min. <br />Test Start Time (TI Y <br />1 1:00am <br />1 1:00am <br />1 1:00am <br />1 1.00am <br />Initial Reading (R <br />13.25 in. <br />12.75 in. <br />12.56 in. <br />12.50 in. <br />I Test End Time (TF <br />-- <br />12:00pm <br />12:00pm <br />12:00pm <br />12:00pm — <br />Final Reading (FF): <br />13.25 in. <br />12.75 in. <br />12.56 in. <br />12.50 in. <br />Test Duration (TF -T,): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />1.00 hr, <br />Change in Reading (RF - R, <br />0,000 in. <br />0.000 in. <br />0.000 in. <br />0.000 in. — <br />Pass]Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />0 Pass [3 Fall <br />M Pass C] Fail <br />Pass 0 Fall <br />Pass 0 Fail <br />• <br />i 11 IM."'poll 1111111 liql lippliq 11�� I': q: 1111 ip <br />MP <br />p <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the info c.oataffied in this report is true, accurateand in full cOmPIIAMO with legal requirements. <br />Technician's Signature: Date. 01/29/15 <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 />