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f � f <br />Spill Bucket Testing ReportForm SWRGB, January 2006 <br />This form is intended for use by contractors perform' `ng <br />annual testing of UST spilt containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility ownedoperator for submittal to the local regulatory agency. <br />7 CAr•11 ITV 1K1Cl1®RAATtnw1 <br />Facility Name: Tracy Blvd Shell & Mini Mart Date of resting: 1/29/13 <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: / / <br />Name of Local Agency Inspector (if present during testing): Stacy Rivera <br />9 TCQTIAI12 f'MK1T0At+Tno uer^®®ww-ri^we <br />llucenseNumber(s): <br />ompany Name: Service Station Systems <br />echnician Conducting Test: Steve Parmenter <br />redentialst: ® CSLB Contractor ® ICC Service Tech. [:]SWRCB Tank Tester ❑Other (Specify) <br />License: 485184 ICC:5311561-UT <br />3 QD11 1 Ql lr•tlCT TCCTu1f± u�rnou w r�^e� <br />Test Method Used: <br />® 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 Fill Bucket <br />02 Plus <br />3 Fill Bucket <br />03 Prem <br />4 Fill Bucket <br />04 Diesel <br />Bucket Installation Type: <br />FlDirect Bury <br />x ❑ Contained in Sump <br />E]Direct Bury <br />Q Contained in Sump <br />E]Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />12.00 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 />Q min. <br />1 min. <br />1 min. <br />1 min. <br />Test Start Time (T, ): <br />10:00am <br />10:00am <br />10:00am <br />10:00am <br />Initial Reading (R, ): <br />14.000 in. <br />13.625 in. <br />13.625 in. <br />13.875 in. <br />Test End Time (TF ): <br />11:00am <br />11:00am <br />11:00am <br />11:00am <br />Final Reading (RF ): <br />14.000 in. <br />13.625 in. <br />13.625 in. <br />13.875 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 />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />® Pass ❑ Fail <br />] Pass ❑Fail <br />IM Pass ❑ Fail <br />® 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 Information contained In this report is true, accurateand In full compliance with legal requirements. <br />Technician's Signature- ,X, Date: 1/29/13 <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 />