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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 (f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: RAMOS OIL I Date of Testing: OCT 1, 2009 <br /> Facility Address: 10842 S. HARLAN ROAD, FRENCH CAMP,CA 95231 <br /> Facility Contact: DAVE NELSON I Phone: (916)371-3289 <br /> Date Local Agency Was Notified of Testing: SEPT 21, 2009 <br /> Name of Local Agency Inspector(fpresent during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705 (CSLB Contractor) -- 5297888-UT(ICC Service Tech.) -- 06-1672(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other(Specify) <br /> Test Equipment Used:VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) DIESEL FILL <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 14.00" <br /> Bucket Depth: 13.00" <br /> Wait time between applying 10 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 AM <br /> Initial Reading(RI): 13.00" <br /> Test End Time(TF): 10:00 AM <br /> Final Reading(RF): 13.00" <br /> Test Duration(TF—TI): 1 HR <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: Z Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail ❑ 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: �`— Date: OCT 1,2009 <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 />