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SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of USTspill containment structures. The completed form and printouts from tests (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency I. FACILITY INFORMATION Facility Name: UNITED #5446 1 Date of Testing: 511112016 Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 Facility Contact: ALLEN FAASS I Phone: (949) 289-5286 Date Local Agency Was Notified of Testing: 4/22/16 Name of Local Agency Inspector (if present during testing): COUNTY OF SAN JOAQUIN ENV HLTH INSPECTOR 2. TESTING CONTRACTOR INFORMATION Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Technician Conducting Test: RICHARD THOMAS Credentials: ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) License Number(s): 803705 (CSLB Contractor) - 5254736 -UT (ICC Service Tech) - 06-1672 (SWRCB Tank Tester) 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) Test Equipment Used: VISUAL - TAPE MEASURE Equipment Resolution: I/16" Identify Spill Bucket (By Tank Number, Stored Product, etc.) DIESEL FILL 87 FILL 91 FILL Bucket Installation Type: ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ® Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump Bucket Diameter: 12" 12" 12" Bucket Depth: 12.25" 12" 11.50" Wait time between applying 10 MIN vacuum/water and start of test: 10 MIN 10 MIN Test Start Time (Ti): 10:00 10:00 10:00 Initial Reading (Ri): 10.75 10.50" 10" Test End Time (TF): 11:00 11:00 11:00 Final Reading (RF): 10.75" 10.50" 10" Test Duration (TF - Ti): 1 HR 1 HR 1 HR Change in Reading (RF - Ri): 0 0 0 Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: f ----z "�AA�---'� Date: 511112016 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.