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RECEIVED <br /> MAR Z 7 2017 <br /> E VIRON ENTAL HEALTH <br /> Spill Bucket Testing Report Form PER IT/SERVICES <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quick N Easy Mart Date of Testing: 2/9/2017 <br /> Facility Address: 2057 S EI Dorado Stockton CA.95015 <br /> Facility Contact: Phone: <br /> Date Local Agency was notified of Testing: <br /> Name of Local Agency Inspector(if present during testing:) <br /> 2.TESTING CONTRACTOR INFROMATION <br /> Company Name:Mid Valley Consulting&General Engineering <br /> Technician Conducting Test:Jason Haase <br /> Credentials: CSLB Contractor ICC Service Tech. SWRCB Tank tester <br /> License Number(s): 920985 8165490-UT <br /> 1. SPILL BUCKET TESTING INFORMATION <br /> Test Method Use: x Hydrostatic Vacuum Other <br /> Test Equipment Used: Pump Equipment Resolution: <br /> Identify Spill Bucket(By Tank L UNLEADED 2 PREMIUM 3 4 <br /> Number,Stored Product) <br /> Bucket Installation Type: X Direct Bury X Direct Bury Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: 11" 11" <br /> Bucket Depth: 12" 13.5" <br /> Wait time between applying 15 MIN 15 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): 10:15 10:15 <br /> Initial Reading(111): 11" 12.5" <br /> Test End Time(Tf): 11:15 11:15 <br /> Final Reading(Rf): 11" 12.5" <br /> Test Duration(Tf-TI): IHR IHR <br /> Change in Reading(Rf-Rl): 0 0 <br /> Pass/Fail Threshold or Criteria: .25" .25" <br /> Test Results: X Pass Fail X Pass Fail Pass Fail Pass Fail <br /> Comments: - (include information on repairs made prior to testing,and recommended follow-up for failed tests,) <br /> CertLtWr4ion of Technician Responsible for Conducting This Testing <br /> I hereby certify that all inform ti n in this report is true,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 2/9/2017 <br />