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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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facil' Name: UPS I Date of Testing: 05/24/2018 <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: 05-23-2018 <br /> Name of Local Agency Inspector(f present during testing: Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Cam Name: RL Stevens Co. <br /> Technician Conducting Test: David Pereira <br /> Credentials': [x]CSLB Contractor [x] ICC Service Tech. D SWRCB Tank Tester D Other(Specify) <br /> License Number(s): 5240739-UT,415807 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [x]Hydrostatic D Vacuum D Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank I T-1 Diesel 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: [xj Direct Bury D Direct Bury D Direct Bury D Direct Bury <br /> D Contained in Sump D Contained in Sump D Contained in Sq!np D 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(Ti): 1:55 <br /> Initial Reading(Rj): 111/2 " <br /> Test End Time(TF): 2:55 <br /> Final Reading(RF): 11 '/" <br /> Test Duration(TF—T,): 1 hr <br /> Change in Reading(RF-R,): 0 <br /> Pass/Fail Threshold or 1/16" <br /> Criteria: <br /> Test Result: [z] Pan 11 Fall £] Pass ❑Fail ❑ Pass ❑Fail ❑ Pass 0 Fail <br /> C®mments—(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> d to replace swivel ton fill adaptor and retest <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I kereby certify that all the lnfornsatlon contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:05/24/2018 <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 />