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i4CE D <br /> 1 e ft <br /> J.0 "C18 <br /> L U,1 SWRCB.h111LJ,-11'\ 2006 <br /> Spill Bucket Testing Report FoipIMONM ENTAL <br /> Thisfin-in is intended fir-use by coniraciors per10rnfiiW annual testing of USTspill coVf@AAj?## (11?d <br /> printoulsftoin applicah"C", 1v ......... <br /> fiv subaiitial to the local regii <br /> 0" agm"l, <br /> 1. FACILITY INFORMATION <br /> Facility Name- H �� M K"Ifw -,F.Pvr- IAWC)X r7late of T 9'1 '20 1­7- <br /> est!riu: <br /> Facility Address: 2501 E.JACKSON <br /> Facility Contact: MODESTO Phone: 209-838-3971 <br /> Date Local Agency Was Notified ot"Festing: <br /> Name of Local Agency Inspector(ffpresent duritag testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SFRVICES <br /> Technician Conducting Test: PFTFR WESTBROOK <br /> Credentials': CSI.B Contractor X ICC Service Tech. SW RC13 Tank Tester Other(Specf,h,) <br /> License Number(s):8772623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X-- Hydrostatic Vacuum Other <br /> _LLqu=ipnient Resolution: TAP <br /> Test Equipment Used: WATER <br /> Identify Spill Bucket(4v Tank 1 91 FILL 2 DSL FILL <br /> Number, Stored Product, ew,) <br /> X <br /> Bucket Installation Type: Dii,:6 fury U11CL1 bury Direct Bucy Direct Butt <br /> Contained in Sump- Contained in SUMP Contained in Sump Contained in Sul <br /> Bucket Diameter: 12" 12' <br /> Bucket Depth: 14" 14" <br /> Wait time between applying <br /> 30-MIN 30-MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:30AM 11:30AM <br /> —--------- <br /> Initial Reading(Ri): 14" 14" <br /> Test End Time(Tr): 12:30PM 12:3013M <br /> —Final Reading(R,:): 14" 4" <br /> Test Duration(Ti -- Tj): I-HR I-IIR <br /> Change in Reading(Rr-Rj): NONE 10" <br /> Pass/Fail Threshold or <br /> PASS FAILED <br /> Criteria: <br /> Test Result: X Pass Fail Pass X Fail Pass Fail 1,1 Pass 1 Fail <br /> Comments— (inchule iqlbrntalion ori revairs made prior to tesrnlg, and te"I" <br /> RE RAIRED 91 AND DSL DRAM[ VALVE RETE�1D�_1 PA SL <br /> _SS-ED D <br /> - FAILED FUSSIBIELEAKjN-BUCKET ITSELF <br /> ---------- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I herekv certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> n <br /> Technician's Signature: D 1 -17 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local <br /> may be more stringent. <br />