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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 /> 1. FACILITY INFORMATION <br /> Facility Name:YRC#813(Tracy) I Date of Testing:2-13-2020 <br /> Facility Address:1535 E.Pescadero Avenue Tracy 95304 <br /> Facility Contact:Ruben Byerley Phone:(913)344-3644 <br /> Date Local Agency Was Notified of Testing:1/24/2019 <br /> Name of Local Agency Inspector(if present during testing):Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Confidence UST Services,Inc. <br /> Technician Conducting Test:Michael Stromecki <br /> Credentials': 0 CSLB Contractor BICC Service Tech. 0 SWRCB Tank Tester Other(Spec) <br /> License Number(s): 804904 8339168 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ©Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Ruler Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 T-6 Waste Oil tank Field 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: ®Direct Bury 0 Direct Bury 0 Direct Bury 0Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12 <br /> Bucket Depth: 15 <br /> Wait time between applying10 „� <br /> s, raa% <br /> vacuum/water and start of test: - q6 <br /> Test Start Time(Ti): 11:04 AM <br /> Initial Reading(Rj): 131/2" <br /> Test End Time(TF): 12:04 PM <br /> Final Reading(RF): 131/2" <br /> Test Duration(TF—Ti): 60 min 1 / RONME T <br /> Change in Reading(RF-Ri): 0" DEP <br /> Pass/Fail Threshold or +/-1/16" <br /> Criteria: <br /> Test Result: p Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OP\A/mani ifarturar'c puhlichari tact nrnrarii ira anri pace/fail rritaria fnllnwari Saa attarhert tinri imantaflnn fnr cpprofr.c <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:2-13-2020 <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 />