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A <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Gas Depot 2 1 Date of Testing: 12/30/2014 <br />Facility Address: 1330 E. Yosemite Ave. Manteca, Ca. 95336 <br />Facility Contact: Kevin Phone: (209) 82M -EG E: <br />I V r <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): Elena Manzo JAN 3 0 2015 <br />2. TESTING CONTRACTOR INFORMATION ENVIRONMENTAI _ <br />wa <br />Company Name: Reliable Petroleum Services, Inc. -t:01 <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': x CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 883706 5250451 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure Equipment Resolution: N/A <br />Identify Spill Bucket (By Tank 1 Tl: 87 Fill <br />Number, Stored Product, etc. <br />2 T2: 91 Fill 3 T3: Diesel Fill <br />4 T4: <br />Bucket Installation Type: Direct Bury <br />x Contained in Sump <br />Direct Bury Direct Bury <br />x Contained in Sump x Contained in Sump <br />Direct Bury <br />Contained in Sum <br />Bucket Diameter: 12" <br />12" 12" <br />Bucket Depth: 14" <br />13''/2" 171/2" <br />Wait time between applying 1 minute <br />vacuum/water and start of test: <br />1 minute 1 minute <br />Test Start Time (TI): 1:36 p.m. <br />3:02 p.m. 1:36 p.m. <br />Initial Reading (Ri): 11 '/2" <br />113/8" 14'/4" <br />Test End Time (TF): 2:36 p.m. <br />4:02 p.m. 2:36 p.m. <br />Final Reading (RF): 11''/2" <br />113/8" 141/4" <br />Test Duration (TF— TI): <br />1 hr <br />1 hr 1 hr <br />Change in Reading (RF - RI): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" 1/16" <br />Test Result: <br />x Pass ❑ Fail <br />x Pass ❑ Fail x Pass ❑ Fail <br />Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Repaired drain valve on 91 fill. <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 12/30/2014 <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 />