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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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TRACY TRUCK&AUTO Date of Testing: 4/16/2014 <br /> Facility Address: 3940 TRACY BLVD <br /> Facility Contact: DEBBIE AND CJ Phone: 209-532-5006 <br /> Date Local Agency Was Notified of Testing: 4/10/2014 <br /> Name of Local Agency Inspector(ifpresent during testing): THUY T <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: KAISER COMMERCIAL PETROLEUM <br /> Technician Conducting Test: GREG KAISER <br /> Credentials': Z CSLB Contractor 0 ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> [_j:icense Number(s): CSLB#859535,ICC#5252318-UT <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:TAPE MEASURE AND H2O Equipment Resolution: <br /> AQAW= g—,-- <br /> T=TREG UNL 2 TANK 2 SUPER 3 TANK 3 DIESEL 4 TANK 4 DIESEL <br /> identify Spill Bucket(By Tank <br /> Number,Stored Product, etc. WEST EAST <br /> Bucket Installation Type: 0 Direct Bury Z Direct Bury 0 Direct Bury 0 Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump <br /> Bucket Diameter: 11 INCH 11 INCH I I INCH 11 INCH <br /> Bucket Depth: 13 INCH 13 INCH 12 INCH 12 INCH <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:00 9:00 9:00 9:00 <br /> Initial Reading(111): 11 Y2 INCH 11 1/2 INCH 12 INCH 12 INCH <br /> Test End Time(TF): 10:00 10:00 10:00 10:00 <br /> Final Reading(RF): 11 1/z INCH 11 Y2 INCH 12 INCH 12 INCH <br /> Test Duration(TF—Tj): I HOUR I HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or PASS PASS PASS PASS <br /> Criteria: <br /> Test Result: 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> NOTE: Test water was placed in drum on site, labeled, sealed for removal Der <br /> custmer. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contain d in this report is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: Date: 4/16/2014 <br /> State laws and regulations do not curre t require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />