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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 ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: United Parcel Service I Date of Testing: 6-7-2012 <br /> Facility Address: 1532 North Broadwa-y—Stockton,CA 95205 <br /> Facility Contact: Kasi-Montgomery—Plant Engineering I Phone: (916)709-6616 <br /> Date LwA Agenc) Was Notified of Testing: 5-24-2012 <br /> Name of Local Agency Inspector 4present during testing): Jeff Wong-San Joaquin County E.H.D. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: PETRO-TECHZ Environmental Services <br /> Technician Conducting Test: Dan Zeman <br /> Credentials': R CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester F1 Other(Specify) <br /> License Number(s): ICC Service Technician No.:5243781-UT—CA SWRCB Tank Tester Ucense,No.: 1535 <br /> J. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hy drostatic Vacuum Other: <br /> Test Equipment Used: Tape Measure—Lake Test Equipment Resolution: 1/16" <br /> ldentiSpill Bucket(By Tank 1 Diesel <br /> Number, Stored Product, etc.) <br /> Bucket Installation T3W-. Direct Bury <br /> Bucket Diameter: I I" <br /> Bucket Depth: 13"' <br /> Wait time between app�-%ing 15 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 10:00 am <br /> Initial Reading(Rj): 123/4- <br /> Test End Time(T,): 11:00 am <br /> Final Reading-(RF): 123/4- <br /> Test Duration(TF—Ti): 60 Minutes <br /> Change in Reading(RF-Rj): 0.00 <br /> Pass/Fail Threshold or 1/4"in a 24 HL Period <br /> Criteria: <br /> Test Result: pass <br /> Comments—(include information on repairs made prior to testing, and recomnietidedfollou,-upfor failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSEBLE FOR CONDUCTING THIS TESTING <br /> I hereby eerfify that all the information contained in this report is true,accurate,and in full conrliance with legal require eats. <br /> Technician's Sig Date:June 7.2012 <br /> Page 5 of 5 <br />