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Form 12/2004 <br /> Spill Bucket Testing Form <br /> FACILITY INFORMATION <br /> Facility Name:ESCALON MINI MART I Date of Testing:1-9-14 <br /> Facility Address: 1097 E YOSEMITE AVE ESCALON CA <br /> Facility Contact:BILL I Phone: 209 838 1546 <br /> County: SAN JUAQUIN <br /> Name of Local Agency Inspector(ifpresent during testing): Elena Manzo <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hiff 1100 North J Street Tulare,CA 93274 (559)688-2977 <br /> Technician Conducting Test: ADAM TAYLOR <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A,B,C-61/D40 HAZ License Number: 304147 <br /> SPILL BUCKET CONTAINMENT BOXES <br /> Facility is Not Equipped With Spill/Overfill Containment Boxes 11 <br /> Spill/Overfill Containment Boxes are Present,but were Not Tested 11 <br /> Test Method Developed By: 0 Spill Bucket Manufacturer 0 Industry Standard x Professional Engineer <br /> El Other(Specify) <br /> Test Method Used: 11 Pressure 0 Vacuum x Hydrostatic <br /> 0 Other(Specify) <br /> Test Equipment Used: VISUAL Equipment Resolution: <br /> SEEM= Bucket:87 Bucket:91 Bucket: Bucket: <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 16 16 <br /> Wait time between applying <br /> pressure/vacuum/water and I I <br /> starting test: <br /> Test Start Time: 900 900 <br /> 09 <br /> Initial Reading(R�: 16 16 2014 <br /> Test End Time: 1000 1000 <br /> Final Reading(RF): 16 16 ENVIF U—N'M'—NTAL <br /> Test Duration: IHR IHR HE i DEPARTIME�.!T <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or PASS PASS <br /> Criteria: -E <br /> Test Result: [IX Pass F" 11-EX Pass UFail Pan 0 FaR El Pass 0 Fail <br /> TECHNICIANADAMTAYLOR DATE 1-9-14 <br /> SIGNATURE COMPANY—FRANZEN-HILL— <br />