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RECEIVED <br /> MAY 1 '3 22018 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form ENVRONMENTAL <br /> y- <br /> This form is intended for use by <br /> y contractors performing annual testing of UST spill containment structures. The compr&J,hallrRal--�Fd'PT�,AFNT <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: ShelIfTesoro— =Date of Testing:05/07/18 <br /> Facility Address: 2705 Country Club Blvd. Stockton, CA 95204 <br /> Facility Contact: Roy Halloun (209)465-4756 <br /> Date Local Agency Was Notified of Testing: 4/24/18 <br /> Name of Local Agency Inspector (if present during testing): Stacy Riviera <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Kris Bell_ <br /> Credentialsi: Z CSLB Contractor M ICC Service Tech. [:] SWRCB Tank Tester [] Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: IS] Hydrostatic ❑Vacuum Ej Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket Fill Bucket ----T-3Fill Bucket 4 <br /> Number,Stored Product, etc.) 01 -RE u 02-Prem 03-Diesel <br /> E] Direct Bury 0 Direct Bury E] Direct Bury E] Direct Bury <br /> Bucket Installation Type: <br /> ® Contained in Sump ® Contained in Sump Contained in Sump El Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 13.00 in. 15.50 in. <br /> Wait time between applying 10 min. 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti 9:30am 9:30am 9:30am <br /> Initial Reading(R 13.875 in. 12.500 in. 13.375 in. <br /> Test End Time(TF 10:30am —10-.30am 10:30am <br /> Final Reading(P,-): 13.875 in. 12.500 in. 13.375 in. <br /> Test Duration(TF-Ti): 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 RdSUlt: [K Pass E] Fail Pass [:] Fall Pass [3 Fail ❑Pass 7 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 /> hereby certify that all the In co fined in this report is true,accurateand in full compliance with legal requirements. <br /> Technician's Signature: Date, 05/07/18 <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 />