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eas� <br />UG 17 2016 C-C.L. C..P,�ANCE <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill contairimentst uoz -es. 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: 24 Hours Gas & Mart I Date of Testing: 08/09/2016 <br />Facility Address: 1901 S. EI Dorado Street, Stockton, CA 95206 <br />Facility Contact: Sayed I Phone: (209) 207-1252 <br />Date Local Agency Was Notified of Testing: 07/21/2016 <br />Name of Local Agency Inspector (ifpresent during testing): Victoria McCartney <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ECO-CHEK Compliance, Inc. <br />Technician Conducting Test: Nik Zagorov <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 958763 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum ❑ Other <br />Test Equipment Used: Caldwell Level Change Indicator Equipment Resolution: 0.0025 <br />Identify Spill Bucket (By Tank <br />187 <br />2 91 3 <br />4 <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />® Direct Bury <br />® Direct Bury ❑ Direct Bury <br />❑ Direct Bury <br />❑ Contained in Sum <br />❑ Contained in Sum ❑ Contained in Sum <br />❑ Contained in Sum <br />Bucket Diameter: <br />12 Inches <br />12 Inches <br />Bucket Depth: <br />12 Inches <br />12 Inches <br />Wait time between applying <br />10 Minutes <br />10 Minutes <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />01:45 PM <br />01:45 PM <br />Initial Reading (RI): <br />12 Inches <br />9 3/4 Inches <br />Test End Time (TF): <br />02:45 PM <br />02:45 PM <br />Final Reading (RF): <br />12 Inches <br />9 3/4 Inches <br />Test Duration (TF — TI): <br />60 Minutes <br />60 Minutes <br />Change in Reading (RF -RI): <br />0 Inches <br />0 Inches <br />Pass/Fail Threshold or <br />0.0025 Inches <br />0.0025 Inches <br />Criteria: <br />Test Result: <br />® Pass 0 .Fail '- <br />. ® IP [],Fall- <br />® Pass ❑ Fail <br />Q Pass' ®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 />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: WZr pV Date: 08/09/2016 <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 />