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From: Belshire Environment Fax: (949) 4MS210 To: 12094683433@rcfax.cc Fax: +12094683433 P ge 2 of 2 0112012016 2:38 PM <br />p , `. SWRCB, January 2006 <br />Spill Bucket Testing Report For <br />This form. is intended for use by contractors perfonning annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to tyre facility omaterloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Nance: Kaiser Stockton Date of Testing: 1/5/2016 <br />Facility Address: 7373 West Lane <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 11/2312015 <br />Name of Local Agency Inspector (if present during testing): ®w , n A , <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Belshire Environmental Services, Inc. I <br />Technician Conducting Test: David Walker F,1711r <br />Credentialsi: F CSLB Contractor ❑ICC Service Tech. E-] SWRCB Tank Tester [*..-.]other (Specify) <br />License Number(s): 808313 <br />Test Method Used: <br />3. SPILL BUCKET TESTING INFORMATION <br />®Hydrostatic El vacuum Q other <br />Test equipment Used: visual <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />I DSL Fill <br />2 3 4 <br />Bucket Installation Type: <br />Direct Bury <br />Bucket Diameter: <br />14" <br />Bucket Depth: <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 Minutes <br />Test Start Time (Ti): <br />03:39 PAA <br />Initial Reading (Rr): <br />1.5" From Top <br />Test End Time (Tr): <br />04:39 PAA <br />Final Reading (Rp): <br />1.5" From Top <br />Test Duration (Tp — T1): <br />1 Hour <br />Change in Reading (RF -Rr): <br />o <br />Pass/Fail Threshold or <br />Criteria: <br />No visual Loss <br />Test Result: k Pass 0 Fall <br />t:U111t11ellfSS — include In anrtation. on repairs made <br />El Pass O Fait ❑ Pass ❑ Fail D Pass ci Fall <br />prior to t@stip ,and r@COItJm@fill@d o1low-t1) or ailed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the Infonnation contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature,_ \j ,f Date: 1/512016 <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 />