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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, rom tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quick Stop Market Date of Testing: 11-22-10 <br /> Facility Address: 2057 S El Dorado,Stockton,CA 95206 <br /> Facility Contact: Phone: 209-463-6474 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Henderson Maintenance Company <br /> Technician Conducting Test: Gavin Williams <br /> Credentialsi: IXI CSLB Contractor [Xj JCC S--,;-'Tech. v SWRCB T '1,Tester a. 1- _ther(SpeCihil <br /> iCC:8016288-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: XHydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Water <br /> Identify Spill Bucket(By Tank 1-87 2-91 3 4 <br /> Number, Stored Product, etc. <br /> Y Tlirr�-i P�,T,.; y rl;r"ni <br /> Direct Bury 0 Direct Bury <br /> Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: H,, <br /> Bucket Depth: 15 14" <br /> Wait time between applying 1h 1h <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00a 9:00a <br /> Initial Reading(RI): 14" 13" <br /> Test End Time(TF): I <br /> 10:00a 10-00a <br /> 1 . <br /> " <br /> f 111al Reading(AF). Iq <br /> Test Duration(TF-Tj): Ihr lhr <br /> Irlhan"in Leading VA: 0 0 <br /> - <br /> Criteria: <br /> Test Resuft: X Pass 0 Fail X Pass 11 Fail 0 Pass 0 Fail 0 Pass 0 Fa!! <br /> Comments-(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RE-SP0N-Q!--S-- -E F;-U <br /> X Afthe ln3lr=-!Lon eanha-wed J-416 "V fj�aL� a ms's:. z <br /> Technician's Signature: Date: 1 ( h <br /> zi to <br /> `tate <br /> laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />