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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisform 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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Mid City Ca FO Regan Date of Testing:81712018 <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(if present during testing):aaron hang <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SunWest Engineering Const., Inc. <br /> Technician Conducting Test:Ruben Becerra <br /> Credentials t: ❑CSLB Contractor a ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s):5302139 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑✓ H drostatic []vacuum ❑Other <br /> Test Equipment Used:measuring tape/visual Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 UST#313 2 3 4 <br /> Number,Stored Product, etc) <br /> Bucket Installation Type: ❑Direct Bury []Direct Bury ❑Direct Bury []Direct Bury <br /> ❑✓Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter(inches): 12" <br /> Bucket Depth(inches): 13" <br /> Wait time(min)between applying <br /> vacuum/water and start of test: 15 minutes <br /> Test Start Time(Tt): 8:30am <br /> Initial Reading(RO: 1.0 inch below grade <br /> Test End Time(TF): 9:30am <br /> Final Reading(RF): 1.0 inch below grade <br /> Test Duration(TF—Tt): 60 minutes <br /> Change in Reading(RF-Ril: 0.00 <br /> Pass/Fail Threshold or 0.002 <br /> Criteria: <br /> Test Result: ✓❑Pass ❑Fail ❑Pass ❑Fail ❑Pass []Fall ❑Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-u or ailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the information contained in this report Is true,accurate,and in full compliance with legal requirements. <br /> iggelly .0 0709:55:33-0Tby Ruben u <br /> Ruben Becerra Det,:2018 <br /> Technician's Signature: Date:-817/2018 <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 />