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C <br />11 <br />0 SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />Thisform is intendedfor use by contractors performing annual testing of USTspill containment structures. The completedform and <br />printoutsftom tests (if applicable), should be provided to thefacility ownerloperatorfor submittal to the local regulatory agency. <br />Facility Name: TRACY TRUCK AND AUTO I Date of Testing: 4-23-2012 <br />Facility Address: 3940 TRACY BLV <br />Facility Contact: DEBBIE AND CJ <br />Phone: 2098325006 <br />Date Local Agency Was Notified of Testing: 4-18-2012 <br />Name of Local Agency Inspector (rfpresent during testing): THUY TRAN <br />Technician Conducting Test: GREG KAISER <br />Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other (Specijy) <br />License Number(s): 859535 5252318 -UT <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: TAPE MEASURE AND H20 <br />Equipment Resolution: <br />I REG UNL <br />2TANK 2 SU PER 13TANK3DIESEL <br />WEST <br />4TANK 4 DIESEL <br />EAST <br />Bucket Installation Tyi" <br />irect Bury <br />1ry <br />0 Contained in <br />X Direct B <br />0 Contained i Sump <br />X Direct Bury <br />El Contained in Sump <br />X Direct Bu <br />11 Contained in Sump <br />Bucket Diameter: <br />Bucket Depth: <br />ait time between applying <br />vacuum/water and start of test: <br />Test St T. <br />Test Start Time (Tj): <br />Initial Readin <br />Initial Reading (111): <br />Test End Time (TF): <br />Final Reading <br />EF <br />Test Duration (TF — Tj): <br />A <br />IUD <br />Change in Reading (Rf: - Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />?YML� <br />-!FAIL% <br />Test Result: <br />X Pass <br />X Pass 0 Fail <br />X Pass 0 Fail <br />CoMments — (include information on repairs made prior to testing, q"commendedjbqq-�4��ailed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />b <br />Technician's Signature: <br />j. State laws and regulation not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />