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0 • 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. — FACILITY INFORMATION <br /> Facility Name: RIPON SHELL f Date of Testing: 1-17-2013 <br /> Facility Address: 341 E. Main St <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): Muni <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Henderson Maintenece <br /> Technician Conducting Test: Charles Ferrucci <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 5323096-UT <br /> 3 SPILL BUCKET TESTING INFORMATION <br /> j Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used Water,Tape Measure,Stop Watch Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 regular fill 2 premium fill 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: 12 12 <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1411 1315 <br /> Initial Reading(Rj): 12 12.5 <br /> Test End Time(TF): 1511 1415 1 <br /> Final Reading(RF): 12 12.5 <br /> Test Duration(TF—Tj): 1 hr I hr <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: rs 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 /> -Replaced OPW Fill Cap to yet passiny- result on rev-ular fill bucket. <br /> CERTIFICATION O TEC ICIAN R SIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the i rm 'i "this is true,accurate,and in full compliance ith legal requirements. <br /> Technician's Signature: / Date: <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 />