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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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Shell/Tesoro Date of Testing:08/28/18 <br /> Facility Address: 13975 E. Hwy 88 Lockeford, CA 95237 <br /> Facility Contact: Guillermo Lopez (209) 727-0823 <br /> Date Local Agency Was Notified of Testing: 7/24/18 <br /> Narne of Local Agency Inspector (if present during testing): Zuna Barker <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Kris Bell <br /> Credentialsi: ®CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8833000 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket [T—Fill Bucket 4 <br /> Number, Stored Product,etc.) 01 - Re u 02 -Prem 03- Diesel <br /> E] Direct Bury E] Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> ® Contained in Sump ® Contained in Sump ® Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 14.00 in. 14.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 10 min. 1 Q min. 1 Q min. <br /> Test Start Time(T,): 9:50am 9:50am 9:55am <br /> Initial Reading(RI ): 13.750 in. 13.375 in. 13.625 in. <br /> Test End Time(TF): 10:50am 10:50am 10:55am <br /> Final Reading(RF): 13.750 in. 13.375 in. 13.625 in. <br /> Test Duration(TF -T1): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,}: 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: Q Pass ❑ Fail 0 Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Replaced DSL Bucket ORing <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the info n ccgtalned in this report is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: Date: 08/28/18 <br /> 1 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 />