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41R,E <br /> N"��, \ 0 5 2018 6C'J-4`N6K C:3taAGl.[NCE <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill con @ m and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for Sun mittgl,tomb jv5q,Mcgqlptory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Shell I Date of Testing: 02/27/2018 <br /> Facility Address: 16500 S. Harlan Road, Lathrop,CA 95330 <br /> Facility Contact: Chris Arbabian 7 Phone: (209)983-0381 <br /> Date Local Agency Was Notified of Testing: 01/05/2018 <br /> Name of Local Agency Inspector(f present during testing): Betty Ho <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nik Zagorov <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 1 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 Sump Contained in Sump ❑ Contained in Sum <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(TI): 09:30 AM 09:30 AM <br /> Initial Reading(RI): 12 5/8 Inches 12 1/2 Inches <br /> Test End Time(TF): 10:30 AM 10:30 AM <br /> Final Reading(RF): 12 5/8 Inches 12 1/2 Inches <br /> Test Duration(TF—TI): 60 Minutes 60 Minutes <br /> Change in Reading(RF-Ri): 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: Zr oV Date:02/27/2018 <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 />