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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(if applicable),should be provided to rhe facility ownerloperator for submittal to the local regulatory agency. <br /> I. FACILITYINFORMATION <br /> Facility Name: ESCALON MINI MART Date of Testing: 11/25/2009 <br /> Facility Address: 1097 E.YOSEMITE <br /> Facility Contact: BILL Phone: 209-838-1546 <br /> Date Local Agency was Notified of Testing: <br /> Name of Local Agency Inspector(if prasent during testing): MUNIAPPA.NAIRU <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill <br /> Technician Conducting Test: Junior Sinco <br /> Credentialsr: X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester Q Other(Specify) <br /> License Number(s). A30660 5246152-UT <br /> 3. SPILL BUCKET TESTING INFORMATION. <br /> Test Method Used: X Hydrostatic ❑Vacuum d Other <br /> Test Equipment Used:CADWELL Equipment Resolution: .0 1 <br /> Identify Spill Bucket(By Tank 1 UNLEADED 2 PREM 3 4 <br /> Number,Stored.Product, etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury ❑Direct Bury ❑Direct Burry <br /> ❑Contained in Spa 0 Contained in SuTp ❑Contained in Sunip ❑Contained in Sum <br /> Bucket Diameter: 1.2' 12" <br /> Bucket Depth: 16" 16" <br /> Wait time between applying 1 M1N, 1 MIN. <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1:00 PM 1.00 PM <br /> Initial Reading(Rr): .01 .01 <br /> Test End Time(TF): 2:00 PM 2:00 PM <br /> Final Reading(RF): .01 .01 <br /> Test Duration(TF—TI): 111R 1 HR <br /> Change in Reading(RR-Rr): 0 0 <br /> Pass/Fail Threshold or Pass Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass 0 Fail ❑ Pass ❑Fall ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTMCATION OF CHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inform on contained In this report is true,accurate,and in full compliance with legal requirements! <br /> Technician's Signature: Date: 11/25/2009 <br /> ' State laws and regulations aot currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />