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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors pet foaming manual testing of UST spill containment stntctures. The completed form and <br /> printouts fi-on tests(if applicable),should be provided to the facility otivner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kaiser Stockton Date of Testing: 7/7/20 <br /> Facility Address: 7373 West Lane <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 5/24/2016 pt _ <br /> Name of Local Agency Inspector(rfPresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Belshire Environmental Services, Inc. <br /> Technician Conducting Test: David Walker <br /> Credentials: d❑CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester [-]Other(Specify)_ <br /> License Number(s): 808313 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 91H drostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Visual Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product,etc.) DSL Fill <br /> Bucket Installation Type: Direct Bury <br /> Bucket Diameter: 14" <br /> Bucket Depth: 12" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 Minutes <br /> Test Start Time(T,): 09:00 AM <br /> Initial Reading(RI): 1.5"From Top <br /> Test End Tinte(TF): 10:00 AM <br /> Final Reading(Rp): 1.5"From Top <br /> Test Duration(TF-Tr): 1 Hour <br /> Change in Reading(RF-R,). 0 <br /> Pass/Fail Threshold or <br /> No Visable Loss <br /> Criteria: <br /> Test Result: OPass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑ Fail <br /> Comments-(include infonnation on repairs made prior to testing,and recommended follotiy-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CC <br /> I hereby certify that all the infonnation contained in this report is trite,aceuratt <br /> Technician's Signature:, U-'�--Q jk-"- <br /> 1 State laws and regulations do not currently require testing to be performed by a qu <br /> may be more stringent. <br />