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9 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />WA hl 3111MV5s I► <br />Facility Name: Hammer Lane Oil Date of Testing: 06/2 /2014 <br />Facility Address: 3304 W. Hammer Lane, Stockton, Ca. 95619 <br />Equipment Resolution:N/A <br />Facility Contact: Mike Phone: (209) 478-929 <br />Date Local Agency Was Notified of Testing: 0 to -® / <br />Name of Local Agency Inspector (f present during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATIONENVIRUNMNIAL <br />Company Name: Reliable Petroleum Services, Inc. <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 RIJCKF.T TF,STING ]INFORMATION <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution:N/A <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 Tl: 87 Fill <br />2 T2. 91 Fill <br />3 T3. Diesel Fill 4 T4: <br />Bucket Installation Type: <br />x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />12 ''/o" <br />12" <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />1 minute <br />1 minute <br />I minute <br />Test Start Time (TI): <br />9:29 a.m. <br />9:29 a.m. <br />9:29 a.m. <br />Initial Reading (RI): <br />11 '/<" <br />11" <br />12 7/8" <br />Test End Time (TF): <br />10:29 a.m. <br />10:29 a.m. <br />10:29 a.m. <br />Final Reading (RF): <br />11 'A" <br />11" <br />12 7/8" <br />Test Duration (TF- Ti): <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF- RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />1/16" <br />Test Result: <br />x Pass ❑ Fail <br />x Pass ❑ Fail <br />x 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 certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: c Date 06/20/2014 <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 />