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0 SWRCB,January 2006 <br /> 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(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Waterloo Food&Fuel Date of Testing:07-02-2010 <br /> Facility Address:3032 Waterloo Rd. <br /> Facility Contact:Randy Singh Phone: 916-628-3300 <br /> Date Local Agency Was Notified of Testing: 07-01-2010 <br /> Nam,-of Local Agency Inspector(ii(present during testing):Jeff Wong <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Reliable Petroleum Services Inc. <br /> Technician Conducting Test:Robert Barnhart <br /> Credentials': X CSLB Contractor X ICC Service Tech. 0 SVvrRCB Tank Tester 0 Other(Specify) <br /> License Number(s):883706 5252540-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 Diesel <br /> Number, Stored Product, etc. Fill Bucket Fill Bucket <br /> Bucket Installation Type: X Direct Bury X Direct Bury 11 Direct Bury 0 Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump El Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 1299 1291 <br /> Bucket Depth: 151/211 131/419 <br /> Wait time between applying 5min 5min <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:00 a.m. 9:00 a.m. <br /> Initial Reading(Rj): 159' 123/811 <br /> Test End Time(TF): 10:05 a.m. 10:05 a.m. <br /> Final Reading(RF): 1599 123/811 <br /> Test Duration(TF—TI): Ihr 5min 1hr 5min <br /> Change in Reading(RF-RI): 10 <br /> Pass/Fail Threshold or 1/1611 1/16" <br /> Criteria: <br /> Test Result: X Pass 0 Fail X Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 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 fall compliance with legal requirements. <br /> Technician's Signature: Date: 07-02-2010 <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 />