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__ / <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: Shell I Date of Testing: 02/29/2016 <br /> Facility Address: 16500 S. Harlan Road, Lathrop, CA 95330 <br /> Facility Contact: Nick Arbabian Phone: (209) 983-0381 _ <br /> Date Local Agency Was Notified of Testing: 01/29/2016 <br /> Name of Local Agency Inspector(f present during testing): Victoria McCartney <br /> 2. TESTING CONTRACTOR INFORMATION MAR 4 9 2016 <br /> Company Name: ECO-CHEK Compliance, Inc. ENVIRONMEN FAL <br /> Technician Conducting Test: Nikola Zagorov � , er�x 07- <br /> Credentials': ® CSLB Contractor ®ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 958763 A <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16 Inches <br /> Identify Spill Bucket(By Tank I Regular 2 Premium 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sum ❑ Contained in Sum ❑Contained in Sump Contained in Sump <br /> Bucket Diameter: 12 Inches 12 Inches <br /> Bucket Depth: 14 Inches 14 Inches <br /> Wait time between applying 10 Minutes 10 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 09:30 AM 09:30 AM <br /> Initial Reading(Ri): 12 7/8 Inches 12 5/8 Inches <br /> Test End Time(TF): 10:30 AM 10:30 AM <br /> Final Reading(RF): 12 7/8 Inches 12 5/8 Inches <br /> Test Duration(TF—Tr): 60 Minutes 60 Minutes <br /> Change in Reading(RF-Rj): 0 Inches 0 Inches <br /> Pass/Fail Threshold or 1/16 Inches 1/16 Inches <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® 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 information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: tl� - V"C>VDate:02/29/2016 <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 />