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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(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CRLLC#5447 1 Date of Testing: 7/16/2012 <br /> Facility Address: 1469 E.HAMMER LANE,STOCKTON, CA 95209 <br /> Facility Contact: ALLEN FAASS Phone: (925)884-0800 <br /> Date Local Agency Was Notified of Testing: 6/8/2012 <br /> Name of Local Agency Inspector(fpresent 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/TAPE MEASURE Equipment Resolution: 1/16" <br /> � <br /> Identify Spill Bucket(By Tank <br /> 91 FILL 89 FILL 87 FILL DIESEL FILL <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ® Direct Bury ®Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12.00" 12.00" 12.00" 12.00" <br /> Bucket Depth: 14.50" 14.125" 14.00" 14.50" <br /> Wait time between applying 10 MIN 10 MIN 10 MIN 10 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:00 AM 9:00 AM 9:00 AM 9:00 AM <br /> Initial Reading(Ri): 14.50" 14.125" 14.00" 14.50" <br /> Test End Time(TF): 10:00 AM 10:00 AM 10:00 AM 10:00 AM <br /> Final Reading(RF): 14.50" 14.125" 14.00" 14.50" <br /> Test Duration(TF—TI): 1 HR 1 HR 1 HR 1 HR <br /> Change in Reading(RF-RI): 0" 0" 0.. 0.0 <br /> Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS <br /> Test IReuit: Pass Q I+aa `Pass ® ;Pass ❑Fail Pass' taxi <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 89 SPILL BUCKET DRAIN VALVE WAS REPLACED <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: 7/16/2012 <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 />