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J AN , CO , , uary 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual festing of UST spill confafnme c pp� F(ie, completed form and, : - <br />printouts from tests (if applicable), should be provided to the facility ownedoperatorfor sub t local regiilaYory agency. . <br />1. FACILITY INFORMATION' <br />Facility Name: Tracy Blvd Shell & Mini Mart Date of Testing: 01/25/17 <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: 12/26/16 <br />Name of Local Agency Inspector (ifpresent during testing): VickiMcCartney <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credentials : ® CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:5297793-UT <br />3. SPILL BUCKET TESTING INFORMATION <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 I uc et <br />01 - Re u <br />2 I UC et <br />02 - Plus <br />3 I UC et <br />03 - Prem <br />4 Fill Bucket <br />04 - Diesel <br />Bucket Installation Type: <br />L]Direct Bury <br />® Contained In Sump <br />F]Direct Bury <br />© Contained in Sump <br />❑ 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 />15.00 in. <br />15.00 in. <br />13.50 in. <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />10 min. <br />Test start Time Ra ): <br />9:17am <br />10:56am <br />9:17am <br />9:17am <br />Initial Reading (R, ): <br />13.938 in. <br />13:875 in. <br />12.875 in. <br />13.313 in. <br />Test End Time (TF ): <br />10:17am <br />11:56am <br />10:17am <br />10:17am <br />Final Reading (F� ): <br />13.938 in. <br />13.875 in. <br />12.875 in. <br />13.313 in. <br />Test Duration (TF -T1): <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 />0 Pass ❑ Fait <br />[ Pass ❑ Fail <br />® Pass ❑ Fail <br />Z Pass ❑ Fail <br />Comments: 89 Failed, Replaced Cap & Adaptor. Retested, Passed <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the 1nn?=za4kn coWainad in this report is true, accurate,and In full compliance with legal requirements. <br />Technician's <br />Date: 01/25/17 <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 />