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E 0 `7 <br /> 4� <br /> �/IK-January 2006 <br /> Spill Bucket Testing Report Form <br /> This'form is intended.1br use by contractors performing annual testing of UST spill contain f;NW�B@W-kA4 <br /> printouts frons tests(if applicable), Yhoultl be provided to the facility ownerloperatorfi)r submittal toy agencv. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Mid City Ca FO Regen Date of Testing:8/30/2017 <br /> Facility Address:13850 Devries Road <br /> Facility Contact;Jonathan Pakele Phone:(916)439-6042 <br /> Date Local Agency Was Notified ofTesting: <br /> Name of Local Agency Inspector("if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SunWest Engineering Const., Inc. <br /> Technician Conducting Test:Ruben Becerra <br /> Credentials: []CSLB Contractor 21CC Service Tech. EISWRCB Tank Tester F10ther(Spec yj) <br /> License Number(s):5302139 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [E]Hydrostatic []Vacuum E]Other <br /> Test Equipment Used:measuring tape/visual Equipment Resolution: <br /> Identify Spill Bucket(4v Tank 1 UST#313 fillbucket 2 3 4 <br /> Number,Stored product, etc.) <br /> Bucket Installation.Type- [:]Direct Bury EjDirect Bury ❑Direct Bury []Direct Bury <br /> ElContained in Sump []Contained in Sump ElContained in Sump ElContained in Sump <br /> Bucket Diameter(inches): 12" <br /> -Bucket Depth(inches): 13" <br /> Wait time(min)between applying <br /> vactaim1water and start of test: 15 minutes <br /> Test Start Time(Tj): 9:30am <br /> Initial lZeading(Rj): 13 inches <br /> Test End Time(TF): 10:30am <br /> Final Reading(RF): 13 inches <br /> Test Duration(TF—Tj): 60 minutes <br /> Change in Reading(RI;-Rj): OM <br /> Pass/Fail Threshold or 0.002 <br /> Criteria: <br /> Test Result: 21 Pass [I Fail 01'ass DFaill E3Pass [].Fail OPass ❑[Fail. <br /> C om ments— (include hiLorination on re airs made prior to testing, and recommended,fi)llow-yL,for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all lite information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> DN.­Rab.8—,.�try seaou"S,.Wt Ew—mg,.-SWC, <br /> Ruben US <br /> Technician's Signature: D­2017.09,30102757.070V Date:8/30/2017 <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 />