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SEP 12 2016 <br /> S W RCB,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 fbrnr and <br /> Irrintouts f-om tests(rf applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Mid City Ca FO Regen Date of Testing:2016-09-02 <br /> Facility Address:13850 Devries Road <br /> Facility Contact:Jonathan Pakele Phone:(916)439-6042 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SunWest Engineering Const., Inc. <br /> Technician Conducting Test:David Smith <br /> Credentials: ❑CSLB Contractor ®TCC Service Tech. ❑SWRCB Tank Tester ❑Other(.Specify) <br /> License Number(s):8260473 <br /> 3. SPILL BUCKET TESTING IN.FORMAT.ION <br /> Test Method.Used: ❑✓H drostatic ❑Vacuum ❑Other <br /> Test Equipment Used:tape measure t visual Equipment Resolution: <br /> Identify Spill Bucket(Bv Tank 1 Tank 1 2 3 4 <br /> Nuurnber•,Stored Product, etc.) <br /> Bucket Installation.Type: ❑Direct Bury ❑Direct Bury []Direct Buy ❑Direct Bury <br /> ❑✓Contained in Sump ❑Contained in Sume ❑Contained in Sum2 ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying <br /> 15 min <br /> vacuunr/water and start of test: <br /> Test Start Time(TI): 0900am <br /> Initial heading(Rr): .5 <br /> Test End Time(TF): 1000a <br /> Final Reading(RF): .5 <br /> "rest Duration(TF—Ti): 1 hr <br /> Change in Reading(RF-RO: 0 <br /> Pass/Fail Threshold or <br /> Criteria: .o <br /> Test Result: QPass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail <br /> Comments— (include information on repairs made prior to tenth ,and recommended ollow-u for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> David Smith- " Sm'� <br /> LV wj.w°� aswc. <br /> arn®e-meab.m,r+n+�a�.o.r�neering.c�.c-us <br /> Technician's Signature: D—2016090110.3737drW Date:2016-09-02 <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 />