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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 owner/operator for submittal to the local regulatory agency. <br />ii Arrr.rrV rNFnRMATinN <br />Facility Name: CRLLC #5446 <br />Date of Testing: 5!12!2015 <br />Facility Address: 9403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAASS Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing: 515195 <br />Name of Local Agency Inspector (ifpresent during testing): FATINAH ZAREEF <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.) — 06-9672 (SWRCB Tank Tester) <br />Z QPrr.r. RUCKF.T TFSTING INFORMATION <br />Test Method Used: <br />N Hydrostatic <br />❑ Vacuum <br />❑ Other (Specify) <br />Test Equipment Used: VISUAL - TAPE MEASURE <br />Equipment Resolution: <br />1/16" <br />91 FILL <br />lj <br />WASTE OIL FILL <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) DIESEL FILL <br />87 FILL <br />Bucket Installation T <br />Type: <br />N Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />N Direct Bury <br />❑ Contained in Sump <br />E] Direct Bury <br />N Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />12" <br />Bucket Depth: <br />12.25" <br />11.75" <br />11" <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 MIN <br />10 MIN <br />10 MIN <br />10 MIN <br />Test Start Time (Ti): <br />8:50 <br />8:50 <br />8:50 <br />8:50 <br />Initial Reading (Rj): <br />10.75" <br />10.25" <br />9.50" <br />10.50" <br />Test End Time (TF): <br />9:50 <br />9:50 <br />9:50 <br />9:50 <br />Final Reading (RF): <br />10.75" <br />10.25" <br />9.50" <br />10.50" <br />Test Duration (TF—Ti): <br />1 HR <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />Test ��ult '� <br />; � p:ass [� Fad : <br />� .Pass ,.; ®Fail <br />N : Pas$ ❑ i�`ael <br />� P'ttss : ❑ F'ai# <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 full compliance with legal requirements. <br />Technician's Signature: I — -z , Ut---5 Date: 511212015 <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 />