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C] v SWRCB, January 2006 Spill Bucket Testing Report For This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable) should be provided to the facility ownerloperator for submittal to the local regulatory agency. r Y c1.11Ci., list, Facility Name: CRLLC 6 Date of Testing: 511512014 Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 Facility Contact: ALLEN PAASS I Phone: (825) 884-0800' Date Local Agency Was Notified of Testing: 5/7114 Name of Local Agency Inspector (if present during testing): THUY TRAN 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 Tesi Method Used: ® Hydrostatic ❑ vacuum ❑ Other (Specify) Test Equipment Used: VISUAL - TAPE MEASURE I Equipment Resolution: 1/16" 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--5 Date: 511512014 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 87 FILL 91 FILL WASTE OIL FILL Identify Spill Bucket (By Tank Number, Stored Product, etc.) DIESEL 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" 12" Bucket Depth: 12" 12" 12.125" 12.375" Wait time between applying vacuum/water and start of test: 10 MIN 10 MIN 10 MIN 10 MIN Test Start Time (Ti): 2:00 PM 2:00 PM 2:00 PM 2:00 PM Initial Reading (Ri): 10.50" 10.50" 10.625" 10.875" Test End Time (TF): 3:00 PM 3:00 PM 3:00 PM 3:00 PM Final Reading (RF): 10.50" 10.50" 10.625" 10.875" Test Duration (TF — TO: 1 FIR 1 HR 1 HR 1 HR Change in Reading (RF -Ri): 0 0 0 0 Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS LTO 9 PM now. !::,Pass. L7.Fa�I. 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--5 Date: 511512014 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.