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0 <br /> 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(cf applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TRACY TRUCK&AUTO Date of Testing: 4/19/2013 <br /> Facility Address: 3940 TRACY BLVD <br /> Facility Contact: DEBBIE AND CJ Phone: 209-832-5006 <br /> Date Local Agency Was Notified of Testing: 4/16/2013 <br /> Name of Local Agency Inspector(fpresent during testing): THUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: KAISER COMMERCIAL PETROLEUM <br /> Technician Conducting Test: GREG KAISER <br /> Credentials': N CSLB Contractor N ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): CSLB#859535,ICC#5252318-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:TAPE MEASURE AND H2O Equipment Resolution <br /> Idents Spill Bucket Tank 1 TANK 1 REG UNL 2 TANK 2 SUPER 3 TANK 3 � .� 4 E� <br /> �,`P (By 3 DIESEL 4 TANK 4 DIESEL <br /> Number,Stored Product, etc. ST EAST <br /> Bucket Installation Type: ®Direct Bury N Direct Bury N Direct Bury N Direct Bury <br /> ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: 11 INCH 11 INCH 11 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(TI): 9:00 9:00 9:00 9:00 <br /> Initial Reading(Rj): 11 INCH 11 INCH 11 '/�INCH 11 <br /> Test End Time(TF): 10:00 10:00 10:00 10:00 <br /> Final Reading(RF): 11 INCH 11 INCH 11'/a 11%s <br /> Test Duration(TF—TO: 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R): 0 0 0 <br /> Pass/Fail Threshold or PASS PASS PASS PASS <br /> Criteria: <br /> Test Result: N Pass ❑Fail N Pass 0 Fail N 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 certtfy that all the in rm on container!in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 4/19/2013 <br /> 'State laws and regulations not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />