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ED <br />CB, January 2006 <br />Spill Bucket Testing Report Form - 1 2011 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures.o orm and <br />printouts from tests (if applicable) should be provided to the facility owner/operator for submi a agency. <br />1 _ FAC7I.iTV iNFnRMATInN <br />Facility Name: UNITED #5446 <br />Date of Testing: 5111/2016 <br />Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAASS Phone: (949) 289-5286 <br />Date Local Agency Was Notified of Testing: 4122116 <br />Name of Local Agency Inspector (f present during testing): COUNTY OF SAN JOAQUIN COUNTY INSPECTOR <br />2. TF.CTING CONTRACTOR INFnRMATinN <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials': N CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 (CSLB Contractor) — 5254736 -UT (ICC Service Tech.) — 06-1672 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: VISUAL - TAPE MEASURE <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />WASTE OIL FILL <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />11.25" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 MIN <br />Test Start Time (Ti): <br />10:50 <br />Initial Reading (RI): <br />9.75" <br />Test End Time (TF): <br />11:50 <br />Final Reading (RF): <br />9.75" <br />Test Duration (TF — Tj): <br />1 HR <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or Criteria: <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />Test Result: <br />Z Pass ❑ Fail <br />❑ Pass ❑Fail ]'m <br />"Pass, ❑ Fail <br />❑ 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 <br />,^ contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: — vAA'�`--�'J Date: 5/11/2016 <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 />