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JAN-20-2012 11:07 Service Station Systems 408 938 8888 P.02 <br /> SWRGf3,January 20b6 <br /> Spill Bucket Testing Report r <br /> This form is intended for=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 owher/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tracy Blvd Shell& Mini Mart Date of Testing:1/5/12 <br /> Facility Address: 3725 N. Tracy Blvd. Tracy, CA 95376 <br /> Facility Contact: Tanya Moore 209)835-7608 <br /> Date Local Agency Was Notified of Testing: 12/21/11 <br /> Name of Local Agency Inspector (if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialst: ®CSLS Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> Ucense Number(s): License:485184 Icc-5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> TestMethod Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:Ill 6 in, <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 Fill Bucket <br /> Nu, Stor-d Product, etc.) 01 Re u 02 Plus 03 Prem 04 Diesel <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 in. 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. 14.00 in. 14.00 in. <br /> Wait time between applying 5 min 5 min. 5 min. 5 min. <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 11:30am 11:30am 11:30am 11:30am <br /> Initial Reading(R, ): 13.000 in. 13.250 in. 13.000 in. 13.125 in. <br /> Test End Tim(TF): 12:30pm 12:30pm 12:30pm 12:30pm <br /> Final Reading(F�): 13.000 in. 13.25)in. 13.000 in. 13.125 in. <br /> Test Duration(Ta-T,): 1.00 hr. 1.0U hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,}: 0.0000 in. 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result,. ®Pass ❑ Fail ® Pass [J Fail EM Pass ❑ Fail ❑x 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: Llho Date: 1/5/12 <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 />