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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(if 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 Date of Testing: OCT 10,2008 <br /> Facility Address: 10842 S. HARLAN ROAD, FRENCH CAMP, CA 95231 <br /> Facility Contact: DAVE NELSON Phone: (916)371-3289 <br /> Date Local Agency Was Notified of Testing: SEPT 29,2008 <br /> Name of Local Agency Inspector(present during testing): JEFF WONG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: ROB NEIMEYER <br /> Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other(Spec) <br /> Test Equipment Used:VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) DIESEL FILL 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: 10.50" 10.50" <br /> Bucket Depth: 14.00" 14.00" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:20 AM 10:20 AM <br /> Initial Reading(RI): 13.00" 12.50" <br /> Test End Time(TF): 10:00 AM 11:20 AM <br /> Final Reading(RF): 12.00" 12.50" <br /> Test Duration(TF—TI): 40 MIN 1 HR <br /> Change in Reading(RF-RI): -1.00" 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: ❑ Pass Z Fail Z Pass ❑Fail ❑;Pass ❑Fail ❑ Pass ❑Fail. <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> RAMOS OIL REPLACED FILL CAP,FILL ADAPTOR GASKET AND DROP TUBE O-RING. <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 10,2008 <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 />