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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 (rf applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />_ F A C11.17V YNTi'nDM A rrTnN <br />Facility Name: CRLLC #5446 <br />Date of Testing: 5/2012013 <br />Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAASS I Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing: 5113113 <br />Name of Local Agency Inspector (f present during testing): GARRET <br />2. TFNTIN(a VONTR A f TnR TNTi n12X4 A TIn1V <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester (Specify) <br />❑ Other <br />License Number(s): 803705 (CSLB Contractor) — 5254736 -UT (ICC Service Tech.) — 06-1672 (SWRCB Tank Tester) <br />'t_ gPTi.I. RITrWF'r TFC'rYMr YTtTU Vlt4ATr(1N <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other (Specify) <br />12" <br />Test Equipment Used: VISUAL - TAPE MEASURE <br />11.875" <br />Equipment Resolution: <br />1/16" <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 />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />DIESEL FILL <br />87 FILL <br />91 FILL <br />WASTE OIL FILL <br />Bucket Installation Type: <br />® Direct Bury <br />® Direct Bury <br />® Direct Bury <br />® Direct Bury <br />10:30 AM <br />❑ Contained in Sump <br />❑ Contained in Sump <br />❑ Contained in Sump <br />❑ Contained in Sump <br />tsucxet mameter: <br />12" <br />12" <br />12" <br />12" <br />Bucket Depth: <br />11.875" <br />12" <br />12" <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 (Tj): <br />9:30 AM <br />9:30 AM <br />9:30 AM <br />9:30 AM <br />Initial Reading (Rj): <br />1.5" FROM TOP <br />1.5" FROM TOP <br />1.5" FROM TOP <br />1.5" FROM TOP <br />Test End Time (TF): <br />10:30 AM <br />10:30 AM <br />10:30 AM <br />10:30 AM <br />Final Reading (RF): <br />1.5" FROM TOP <br />1.5" FROM TOP <br />1.5" FROM TOP <br />1.5" FROM TOP <br />Test Duration (TF — T,): <br />1 HR <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Rj): <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 />�Sf Result: <br />Pass ❑ Fail <br />® Pass ❑ Fait <br />0 Pass ❑ Fail <br />1Z Pass El Fail I <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: — v -� Date: 512012013 <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 />