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0 0 SVIRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containments structures. The completedform and <br /> from tests(if applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> printoutsf I tru es. <br /> 1. <br /> FACILITY INFORMATION <br /> Facility Name: PARKWOOD—GAS N FOOD I Date of Testing: 08-11-09 <br /> Facility Address: 1612 W.Hammer Lane Stockton CA 95206 <br /> Facility Contact: Paul Tiwana Phone: 209482-2580 <br /> Date Local Agency Was Notified of Testing: 08-03-09 <br /> [Name of Local Agency inspector present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> C <br /> Technician Conducting Test: Robert Barnhart <br /> I <br /> C r IS1. <br /> redeEntialsl: X CSLB CoWt�;c_tor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> j s imil <br /> License Number(s): 883706 <br /> E _ 5252540-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Standard Tape Measure <br /> I Equipment Resolution: <br /> Identify Spill Bucket(By Tank _Tl: S_u_p�reme _ ------------ <br /> Fill T2:Unleaded Fill T3:Diesel Fill <br /> Supreme <br /> Number,Stored Product, etc.) Bucket Bucket Bucket <br /> Bucket Installation Type: X Direct Bury X Direct Bury 11 Direct Bury E01 Direct Bury <br /> [37 <br /> 0 Contained in Sum 0 Contained in Sump 0 Containedin0 Contained in SUwMnDp <br /> Bucket Diameter: — 12" 12" 1219 <br /> Bucket Depth: 15" 14 15%99 <br /> Wait time between applying 1 min. <br /> vacuum/water and start of test: linin. I min. <br /> Test Start Time(TI): 12:20a.m 9:14a.m 9:12a.m <br /> Initial Reading(R): 13'/" 13 1/16" 14%11 <br /> Test End Time(TF)- 1:25p.m 10:20a.m 10:21a.m <br /> Final Reading(RF): 13%" 131/16" B 14491 <br /> Test Duration(TI;–TO: thr.5min. 1hr.6min. 1hr.9min. <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" 1/1611 1/16" <br /> Test Result: X Pass 0 Fail X Pass <br /> Comments (include information on repairs made prior 11� 13 1 0 Pass 0 Fail <br /> to testing, and recommendedfollow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE TESTING <br /> Port is true,accurate,and in full compliance with legal requirenten&. <br /> I hereby certify that all the information contained in this re FOR CONDUCTING THIS <br /> Technician's Signature. <br /> _Uz±� Date:08-11-09 <br /> State laws and regulations do not currently require testing to <br /> may be more stringent. be performed by a qualified contractor.However,local requirements <br />