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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 from tests (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION <br />Facility Name: CRLLC #5447 <br />Date of Testing: 7/15/2011 <br />Facility Address: 1469 E. HAMMER LANE, STOCKTON, CA 95209 <br />Facility Contact: ALLEN FAASS I <br />Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing: 6/27/2011 <br />Name of Local Agency Inspector (f present during testing): GARRETT BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 (CSLB Contractor) — 5254736 -UT (ICC Service Tech.) — 06-1672 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: VISUAL <br />Equipment Resolution: TAPE MEASURE <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />87 FILL <br />89 FILL <br />91 FILL <br />DIESEL FILL <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />16" <br />16" <br />16" <br />16" <br />Bucket Depth. <br />13.75" <br />14" <br />13.50" <br />14.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 MIN <br />10 MIN <br />10 MIN <br />10 MIN <br />Test Start Time (Tj): <br />9:00 AM <br />9:00 AM <br />9:00 AM <br />9:00 AM <br />Initial Reading (Rj): <br />13.50" <br />13.75" <br />13.25" <br />14.25" <br />Test End Time (TF) <br />10:00 AM <br />10:00 AM <br />10:00 AM <br />10:00 AM <br />Final Reading (RF): <br />13.50" <br />13.75" <br />13.25" <br />14.25" <br />Test Duration (TF — Tj): <br />1 HR <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Rj): <br />0" <br />0" <br />0" <br />0" <br />Pass/Fail Threshold or Criteria: <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />Test Result: <br />Z Pass ❑ Fail <br />Z Pass ❑ Fail <br />0 Pass ❑ Fail <br />Z 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: �— - A-- Date: 7/15/2011 <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 />