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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 ownerloperator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: UPS Date of Testin : 05/23/2018 <br /> Facility Address: 1532 North Broadway,Stockton.Ca.95205 <br /> Facility Contact: Ramona Powell Phone: 916-373-6874 <br /> Date Local Agency Was Notified of Testing: 05-09-201$ <br /> Name of Local Agency Inspector(tfpresent during testing): Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: RL Stevens Co. <br /> Technician Conducting Test: David Pereira <br /> Credentials': [x]CSLB Contractor [x]ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 5240739-UT,415807 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [x]Hydrostatic 11 Vacuum ❑Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By7TankI T-1 Diesel 2 3 4 <br /> Number Stored Product,Bucket Installation Type [x] Direct Bury D Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in S!Lmp ❑Contained in Snp ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 10:13 <br /> Initial Reading(Rr): 11 '/a " <br /> Test End Time(TF): 11:13 <br /> Final Reading(RF): <br /> Test Duration(TF—TO: 1 lir <br /> Change in Reading(RF-Rf): 0 <br /> Pass/Fail Threshold or 1/16„ <br /> Criteria: <br /> Test Result: Q Pass [x]Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments--(include information on repairs made prior to testing; and recommendedfollow-up forfailed tests) <br /> Had to replace swivel to f 1adaptor and rdest on 5-24-2018 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the Information coigVmW in this report is tare,accurate,and do full compliance with legal requirements. <br /> Technician's Sigtature; Dale:-05/23/2018 <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 />