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SWRCB, January 2006 <br />4tpill Bucket Testing Report Ar. RECT201 <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: Kaiser Manteca Date of Testing: 7/15/2015 <br />Facility Address: 1777 W. Yosemite Avenue <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 7/6/2015 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Belshire Environmental Services, Inc. <br />Technician Conducting Test: David Walker <br />Credentials': ® CSLB Contractor ❑ICC Service Tech. ❑ SWRCB Tank Tester El Other (Specify) <br />License Number(s): 808313 <br />Kms. '' 1 A511!11111 L] lifflIXTAY.Vy G, <br />Test Method Used: ❑d Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Visual Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />1 2 3 <br />Diesel UST <br />Direct Bury <br />4 <br />Bucket Diameter: <br />14" <br />Bucket Depth: <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 Minutes <br />Test Start Time (Tj): <br />08:07 AM <br />Initial Reading (RD: <br />10.5 <br />Test End Time (TF): <br />09:07 AM <br />Final Reading (RF): <br />10.5 <br />Test Duration (TF — TD: <br />1 Hour <br />Change in Reading (RF - Rj): <br />0.0000 _ <br />Pass/Fail Threshold or <br />Criteria: <br />No Visable Leaks <br />Test Result: <br />/❑Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <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:. ft ,� � � Date: 7/15/2015 <br />' State laws and regulations do not currently require testing to be ; prformed by a qualified contractor. However, local requirements <br />may be more stringent. <br />