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Jul 26 06 10:44p Mike Dotten 209-533-2650 p.1 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of CST 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: Mossdale Arco Date of Testing: Tuesday, July 25, 2006 <br />Facility Address: 444 Mossdale Road, Lathrop CA <br />Facility Contact: Nick Bokides Phone: (209) 234-1256 <br />Date Local Agency Was Notified of Testing: Friday, July 21, 2006 <br />Name of Local Agency Inspector (ifpresent during testing): Willy Na <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Alltech Petro Inc, 17759 Buttercup Circle, Sonora CA 95370. (209) 532-7320 <br />Technician Conducting Test: Mike Dotten <br />Credentials': Z CSLB Contractor ICC Service Tech. SWRCB Tank Tester 0 Other (Sped) <br />License Number(s): CSLB 623541; ICC 5259412; Tank Tester 90-1068 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Meth Used: ® Hydrostatic ❑ Vacuum Other <br />Test Equipment Used: 30 minute observed test I Equipment Resolution: 1/8 in. <br />Identify Spill Bucket (By Tank <br />1 Diesel <br />2 Prem 3 Reg <br />4 <br />.Number, Stored Product, etc. <br />Bucket Installation Type: <br />Direct Bury <br />[IIn Sum <br />Direct Bury 19 Direct Bury <br />❑ In Sum ❑ In S <br />❑ Direct Bury <br />❑ In Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />0 <br />0 0 <br />vacuum/water and start of test: <br />Test Start Time (O: <br />!, 10:00 <br />10:00 11:17 <br />Initial Reading (RI): <br />8.00 <br />8.00 8.25 <br />Test End Time (TF): <br />10:30 <br />10:30 11:47 <br />Final Reading (RF): <br />8.00 <br />8.00 11:47 <br />Test Duration (TF — T): <br />30 <br />30 30 <br />Change in Reading (RF -R,): <br />0.00 <br />0.00 0.00 <br />Pass/fail Threshold or <br />0 <br />0 0 <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail ® Pass ❑ Fail <br />❑ Pass ❑Fail <br />l;OMMenlS — (inctude fg rrrmation on repairs made prior to testing, and recommended follow-up for failed tests) <br />Water from the test was placed in a haz barrel out by the dumpsters. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certo that all the informadon contained in this report is true; accurate, and far full conVgaaace with legal requirements. <br />Technician's Signature: Date: 61 2S -10g, <br />