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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SHELL I Date of Testing: 1/14/2009 <br />Facility Address: 341 E. MAIN, RIPON, CA 95366 <br />Facility Contact: ANGLE Phone: (209) 559-4544 <br />Date Local Agency Was Notified of Testing: 1/2/2009 <br />Name of Local Agency Inspector (rf present during testing): MUNI <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: SST -Service Station Testing <br />Technician Conducting Test: Heath McEver <br />Credentials': ❑ CSLB Contractor FICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 5236756 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: IWHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: WATER <br />Equipment Resolution: INCHES <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />l 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />kr Direct Bury <br />❑ Contained in Sump <br />& Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />0845 <br />0845 <br />Initial Reading (Rj): <br />11.5 <br />12 <br />Test End Time (TF): <br />0945 <br />0945 <br />Final Reading (RF): <br />11.5 <br />12 <br />Test Duration (TF — Ti): <br />I HR <br />I HR <br />Change in Reading (RF - R,): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />R Pass ❑ Fail <br />,9 Pass ❑ Fail <br />❑ 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, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />Date: <br />State laws and regulations do not currently require testing to be performed by a qualified c ,ntractor. However, local requirements <br />may be more stringent. <br />