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Spill Bucket Testing Report Form MAY �LW`��b�nuary 2006 This form is intended for use by contractors performing annual testing of UST spill containment strz f�r'R'!�Th �tg�t form and printouts from tests (rf applicable) should be provided to the facility owner/operator for submittal to, the local regulatbry agency. 1. 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: 4122/16 Name of Local Agency Inspector (if present during testing): COUNTY OF SAN JOAQUIN COUNTY 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 (Spec) 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: 1/16" 17 7 Identify Spill Bucket (By Tank Number, Stored Product, etc.) WASTE OIL 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" Bucket Depth: 11.25" Wait time between applying vacuum/water and start of test: 10 MIN Test Start Time (Ti): 10:50 Initial Reading (R,): 9.75" Test End Time (TF): 11:50 Final Reading (RF): 9.75" Test Duration (TF - Ti): 1 HR Change in Reading (RF- Rj): 0 Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS Test Result: ® Pass❑ Fail ❑ Pass E]Fail [3Pass ❑ Fail C]Pass ❑Fall 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: t --1 1-� 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.