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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 regftr2 4016 <br /> 1.FACILITY INFORMATION <br /> Facility Name: CHEVRON Date of Testing: 6/14/20,>6,�� r .� <br /> Facility Address: 444 MOSSDALE City: LATHRUP <br /> Facility Contact: PAL Phone: <br /> Date Local Agency Was Notified of Testing: Monday,May 09,2016 <br /> Name of Local Agency Inspector(tf present during testing): ELENA MANZO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance _ <br /> Technician Conducting Test: TIM BURKART <br /> Credentials': CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): 433159 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> ['est Method Used: Z Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution. 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑ Direct Bury <br /> Bucket.Installation Type: <br /> ❑Contained— Sutn ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11" 11" lilt— <br /> Bucket Depth: 10.75" 11" 12.5" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:00 11:00 11:00 <br /> Initial Reading(R,): 10.75" 11" ill, <br /> Test End Time(TF): 12:00 12:00 12:00 <br /> Final Reading(RF): 10.75" 11" 10.25" <br /> Test Duration(TF—Tj): 1 HR 1 HR 1 HR <br /> Change in Reading(RF—Ri): 0 0 0.75" <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result I Pass ❑Fail L Pass ❑Fail ❑ Pass N Fail ❑ Pass [:] Fail <br /> Comments (include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> DSL BUCKET FAILED, WILL NEED TO BE REPLACED AND RETESTED <br /> 87& 91 SPILL BUCKETS ARE NOT 5 GALLONS, TESTED UNDER 5 GALLONS PER INSPECTOR <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: 1 �"-" Date:6/14/2016 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report <br /> 4 of <br />