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Aug 11 06 03:34p Mike Dotten 209-533-2650 p.1 <br /> r <br /> 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 /> 1. FACILITY INFORMATION <br /> Facility Name: Hammer I-5 Arco Date of Testing: Wednesday,August 09, <br /> Facility Address: 3250 W.Hammer Lane,Stockton CA -zoo <br /> Facility Contact: Wes Parkinson Phone: (209)474-9125 <br /> Date Local Agency Was Notified of Testing: Thursday,June 08,2006 <br /> Name of Local Agency lnspectcr(f present during testing): Willy Ng <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc, 17759 Buttercup Circle,Sonora CA 95370.(209)532-7320 <br /> Technician Conducting Test: Mitre Dotten <br /> Credentials': CSLB Contractor N ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): CSLB 623541; ICC 5259412; Tank Tester 90-1068 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑vacuum 0 Other <br /> Test Equipment Used. Tape measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 Reg 1 2 Reg 2 3 Premium 4 <br /> Number,Stared Product,etc. <br /> Bucket Installation Type: Direct Bury Direct Burry Direct Bury Direct Bury <br /> ®In Sump th Sam In S In Sum <br /> Bucket Diameter- <br /> Bucket Depth: <br /> Wait time between applying 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 09:00 09:00 09:00 <br /> Initial Reading(R1): 8.00 8.00 8.00 <br /> Test End Time(Tr): 10 10:00 10:00 <br /> Final Reading(RF): 8.00 8.00 8.00 <br /> Test Duration(TF—T�: 1.0 1.0 1.0 <br /> Change in Reading(RF-Ri}: 0.00 0.00 0.00 <br /> Pass/Fail Threshold or 1/16" 1/16" 1116" <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑]Fail ❑ Pass ©Fail <br /> Comments—(includeinformation on repairs made prior to testin& and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the hiformaden contahted In this report is true,accurate,and in full complknce with legal requirements. <br /> Technician's Signature: 19j< Date: 8 / � / (0 <br />