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SWRCB,January 2006 <br /> Spill Bucket 'Testing Report Form <br /> '(Tris form is intended for use by contractors performing antral testing of UST sill conta nnrent structures. The conrpleted.form and <br /> printot?ts fi•orn tests(if applicable), should be provided to the faeilit),owner/operator for submittal to the local rcgulatol.r agerur�.: <br /> 1. FACILITY INFORMATION <br /> facility Name: 1-1&M KWIK SERVE BW98 Date of Testing: 10/6,x201.7 y <br /> I-acility Address: 2501 E.JACKSON ` <br /> Facility Contact: MODESTO Phone: 209-838-3971 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testink): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> FCredentialsl: <br /> e L.C.SERVICES <br /> ducting Test: PETER WESTBROOK <br /> �CSLBContractor X ICC Service Tech. ❑SWRCB Tank Tester D Other(Specif) <br /> r(s):8772623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic 0 Vacuum 0 Other <br /> .Test Equipment Used: WATER Equipment Resolution:TAP <br /> Identify Spill Bucket(Ar Tank I DSL FILL 2 3 q <br /> 14uuber, .Stored Pr ochtcl, etc.) <br /> Bucket Urstailation Type: X Direct Bury Direct Bury Direct Bur} :Direct Bur'v , <br /> Contained in Sump Contained in Surnp Contained in Surnp 0 Contained in Sunt <br /> C ticket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying <br /> vaeuumLwater and start of test: 30-MIN <br /> Test Start Time(Ti): 1:15PM <br /> Initial Reading(RE): I I" <br /> rest End Time(Tr): 2:15PM <br /> Final Reading(Rt:): <br /> 11- <br /> Test Duration(Tr—Ti): I-HR <br /> Change in Reading(Rr-Rj): NONE <br /> Pass/Fail Threshold or PASS <br /> Criteria: <br /> Test Result: X Pass Fail Pass X Fail Pass X Fail 0 Pass d Fail <br /> _Comments—(include h?forutation on repairs ntacle prior to testini, and recornrnencied follow-trp for fitilecl tests) - <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING . <br /> I herebl,certlft that all the information contained in this report is trite,accurate,and in fall compliance with legal requirements. <br /> Technician's Signature: Date: <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 />