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QRECEIVE Rce� <br />MAI 0 7 2013 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors per forming annual testing of UST spill containform and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for subm t cP 'iry agency. <br />1. FACILITY INFORMATION <br />Facility Name: Shell I Date of Testing: 02125/2013 <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: 01/28/2013 <br />Name of Local Agency Inspector (f present during testing): Thuy Tran <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ECO-CHEK Compliance <br />Technician Conducting Test: Nikola Zagorov <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specify) <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 <br />Equipment Resolution: 1/16 Inches <br />,.. .. ,� ,�., . .,.r „�..... �, <br />fy p (y Tank <br />Idents Sill Bucket (By <br />Number, Stored Product, etc.) <br />1 Regular 2 Premium <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury ® Direct Bury <br />❑ Contained in Sum ❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12 Inches 12 Inches <br />Bucket Depth: <br />12 Inches 12 Inches <br />Wait time between applying <br />vacuum/water and start of test: <br />10 Minutes 10 Minutes <br />Test Start Time (Tj): <br />01:40 PM 01:40 PM <br />Initial Reading (Rj): <br />9 1/8 Inches 9 5/8 Inches <br />Test End Time (TF): <br />02:40 PM 02:40 PM <br />Final Reading (RF): <br />9 1/8 Inches 9 5/8 Inches <br />Test Duration (TF- TI): <br />60 Minutes 60 Minutes <br />Change in Reading (RF - Rt): <br />0 Inches 0 Inches <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 Inches 1/16 Inches <br />Test Result: <br />® Pass ❑ Fail ® 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: rc>V Date: 02/25/2013 <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 />