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9 HE(;WVEE) P.O.Box 4208 <br /> An Mff Sonora CA 95370 <br /> lite c nm Pe&Z., 0' .JUN 2015 Ca:623541 A-Haz <br /> Phone:209-532-7320 <br /> Compliance without Compromise ENVIRONMENTAL Fax:209-533-2650 <br /> UCA® r)'=0APTW=NT mail@alltechpetro.com <br /> Spill Bucket Testing Report Form www.ailtechpetro.com <br /> 1. FACILITY INFORMATION <br /> Facility Name: Costo #1091 Lodi Date of Testing: 5/19/15 <br /> Facility Address: 2680 Reynolds Ranch Rd. <br /> Facility Contact: Rick Medeiros Phone: 209-366-7332 <br /> Date Local Agency Was Notified of Testing : 5/4/15 <br /> Name of Local Agency Inspector (if present during testing): Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc, P.O. Box 4208, Sonora CA 95370. (209) 532-7320 <br /> Technician Conducting Test: Chad White <br /> Credentials ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester E] Other (Specify) <br /> License Number(s): ICC UST Technician #8152115-UT SWRCB 09-1747 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: One Hour observed test Equipment Resolution: 1/16' <br /> Identify Spill Bucket (By 1 87A Fill 2 87B Fill 3 91 Fill 4 Additive Fill <br /> Tank Number, Stored <br /> Product, etc.) <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® In Sump Z In Sum ®.In Sump ® In Sum <br /> Wait time between <br /> applying vacuum/water 0 0 0 0 <br /> and start of test: <br /> Test Start Time (T,): 10:00 10:00 10:00 10:00 <br /> Initial Reading (R): 3 7/8"above cap 4 1/4"above cap 2 3/4"above cap 1/2" above cap <br /> Test End Time(TF): 11:00 11:00 11:00 11:00 <br /> Final Reading (RF): 3 7/8" above cap 4 1/4"above cap 2 3/4"above cap 1/2"above cap <br /> Test Duration (TF—T): 1.0 hr 1.0 hr 1.0 hr 1.0 hr <br /> Change in Reading (RF-R,): 0.0 0.0 0.0 0.0 <br /> Pass/Fail Threshold or 1/16' 1/16' 1/16" 1/16" <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail I ® Pass ❑ Fail 1 Z Pass ❑ Fail 1 0 Pass E] Fail <br /> Comments — (include information on repairs made prior to testing,and recommended follow-up for failed <br /> 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 <br /> requirements. <br /> Technician: Date: 05-19-2015 <br />