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SWRCB, January 2006 <br />Spill Bucket Testingo 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: Tracy Blvd Shell & Mini Mart Date of Testing: 5/10/13 <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: / / 11 <br />Name of Local Agency Inspector (if present during testing): Thuy Tran 11 <br />Company Name: Service Station Systems <br />Technician Conducting Test: Randy Wilkerson <br />Credentialsi : ❑X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License:485184 ICC:5258560-UT <br />3_ SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />0 Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution: 1 /16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re U <br />2 <br />3 4 <br />Bucket Installation Type: <br />C]Direct Bury <br />® Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />E]Direct Bury E]Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />Bucket Depth: <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />Test Start Time (Ti }: <br />10:05am <br />Initial Reading (Ri ): <br />13.00 in. <br />Test End Time (TF ): <br />11:05am <br />Final Reading (F� ): <br />13.00 in. <br />Test Duration (TF -T1): <br />1.00 hr. <br />Change in Reading (RF - Rj ): <br />0.000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />Test Result: <br />d;Pass .` (_{ i<ail. <br />Pass' :, - ' Fail, <br />❑Pass ❑ 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 />1 hereby certify that all the information contained in this report is true, accurate,and in full compliance with legal requirements. <br />Technician's Signature: Date: 5/10/13 <br />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 />