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0 0 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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(af applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Yosemite 76 Date of Testing: 4/5/2006 <br /> Facility Address: 1700 Yosemite Avenue <br /> Facility Contact: Amba Rai Phone: 209-823-7676 <br /> Date Local Agency Was Notified of Testing: 3/21/2006 <br /> Name of Local Agency Inspector(fpresent during testing): Willie <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Confidence UST Services,Inc. <br /> Technician Conducting Test: Douglas M.Young III <br /> Credentials': X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 804904 , 0878646-UT , 901076 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Lake Test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 Regular 2 Super 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11.0" 11.0" <br /> Bucket Depth: 13.75" 14.25" <br /> Wait time between applying 30 Min. 30 Min. <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12:05pm 12:05pm <br /> Initial Reading(RI): 12.50" 13.25" <br /> Test End Time(TF): 1:05pm 1:05pm <br /> Final Reading(RF): 12.50" 13.25" <br /> Test Duration(TF—TI): l hour 1 hour <br /> Change in Reading(RF-RI): 0.00" 0.00" <br /> Pass/Fail Threshold or 1/16" 1/16" <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail ❑ 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 /> I hereby certify that all the info tion coma' ed in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 4/5/2006 <br /> ' State laws and regulations do not6d4ently requ testing to be performed by a qualified contractor.However,local requirements <br />