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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: 02/17/2012 <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: 02/06/2012 <br />Name of Local Agency Inspector (fpresent during testing): Thuy Tran <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: 1/16 Inches <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, SLC-)— <br />tc.Bucket <br />1 Regular <br />2 Premium <br />3 <br />4 <br />BucketInstallation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12 Inches <br />12 Inches <br />Bucket Depth: <br />12 Inches <br />12 Inches <br />Wait time between applying <br />vacuum/water and start of test: <br />10 Minutes <br />10 Minutes <br />Test Start Time (Tj): <br />10:00 AM <br />10:00 AM <br />Initial Reading (Rj): <br />11 Inches <br />11 Inches <br />Test End Time (TF): <br />11:00 AM <br />11:00 AM <br />Final Reading (RF): <br />11 Inches <br />11 Inches <br />Test Duration (TF — Tj): <br />60 Minutes <br />60 Minutes <br />Change in Reading (RF -Rj): <br />0 Inches <br />0 Inches <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 Inches <br />1/16 Inches <br />°Tat sits .: .Pass.: <br />ail <br />Comments — (include information on repairs made prior <br />Tail `, [ rash :.( PaR ` <br />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: Zr cit/ Date: 02/17/2012 <br />j 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 />