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0 SVVRCB,January 2006 <br /> Spill cket 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 I Date of Testing: 4/29/2015 <br /> Facility Address: 3940 TRACY BLVD, TRACY,CA 95304 <br /> Facility Contact: DEBBIE AND CJ Phone: 209-832-5006 <br /> Date Local Agency Was Notified of Testing: 4/1312015 <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY <br /> 7 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> A <br /> 717711 <br /> "j, r7jVj <br /> Company Name: KAISER COMMERCIAL PETROLEUM N 'JENTAi <br /> Technician Conducting Test: GREG KAISER <br /> Credentials': 0 CSLB;Contractor Z ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): CSLB#859535,ICC#5252318-UT <br /> 3. S BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:TAPE MEASURE AND H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 TANK 1 REG UNIL 2 TANK 2 SUPER 3 TANK 3 DIESEL 4 TANK 4 DIESEL <br /> Number, Stored Product, etc. WEST EAST <br /> Bucket Installation Type: 0 Direct Bury R 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 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(Ri): 11 INCH 11 INCH 12 INCH 12 INCH <br /> Test End Time(TF): 10:00 10:00 10:00 10:00 <br /> Final Reading(RF): 11 INCH 11 INCH 12 INCH 12 INCH <br /> Test Duration(TF—Ti): 1 HOUR I HOUR 1 HOUR 1 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: Pass 0 Fail 9 Pass 0 Fail 0 Pass 0 Fail M 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 per <br /> customer. <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 /> A-4 <br /> Technician's Signature: Date:- 4/29/2015 <br /> State laws and regulations do not curre rewire testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />