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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 />1. FACILITY INFORMATION <br />Facility Name: Shell/Tesoro Date of Testing: 01/26/17 <br />Facility Address: 35 N. Cherokee Ln. Lodi, CA 95240 <br />Facility contact: Grace Keller (209) 369-1525 <br />Date Local Agency Was Notified of Testing: 12/26/16 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credentials': ❑X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:5297793-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:) /16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill B_ucket <br />01 - Re u <br />2I uC et <br />02 - Prem <br />3 rill SUE et 4 <br />03 - Diesel <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />Q Direct Bury <br />❑ Contained in Sump <br />® Direct Bury ❑ Direct Bury <br />❑Contained in Sump ❑Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test start Time (T, ): <br />9:45am <br />9:45am <br />9:45am <br />Initial Reading (F� ): <br />11.500 in. <br />12.188 in. <br />11.750 in. <br />Test End Time (TF): <br />10:45am <br />10:45am <br />10:45am <br />Final Reading (RF ): <br />11.500 in. <br />12.188 in. <br />11.750 in. <br />Test Duration (TF - T i): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />(] Pass ❑Fall <br />Pass ❑ Fail <br />.Pass ❑ Fag ❑ Pass ❑ Fall <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 1n!R=Wkn coVained /n this report is true, accurste,and In full compliance with legal requirements. <br />Technician's <br />Date: 01/26/17 <br />1 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 />