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02/09/2010 11:30 FAX 916 371 2360 BZ SERVICE STATION 10 005 <br /> SWRCR,January 2005 <br /> Spill Bucket Testing Report Form <br /> This fond is intended for use by contractors perfomang annual testing of UST spill containment structures. The completed form and <br /> printouts f om tests(if applicable),.should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> facility Name: Econo Gays I Date of Testing: 12/11/07 <br /> Facility Address: 880 E."Victor Road Lodi,CA 95240 <br /> Facility Contact: Singh Phone: 209-369-0958 <br /> Date Local Agency Was Notified of Testing; 11/20/07 <br /> ]Name of Local Agency Inspector(f present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Tedmician Conducting Test: Ed Steams <br /> Credentials': X CSLB Contractor X TCC Service Tech. 0 SWRCB Tank Tesicr ❑Other(Specify) <br /> License Number(s): 433159, 5250492 <br /> 3, SPILL BUCKET TESTING INFORMATION <br /> 'Pest Method Used: X I-I ostatie ❑Vacuum ©Other <br /> Test Equipment Used; Tape Measure Equipment Resolution: <br /> Identify SpilI Bucket(By Tank 1 87 2 91 3 Diesel 4 <br /> Narmber,Stored Product,etc.) <br /> Bucket installation T X Direct Butt' X Direct Bury X Direct Bury ❑Direct Bury <br /> ❑Contained in Sump Q Contained in SumpU Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time CFO: 2:00 2:00 2:00 <br /> Initial Reading(R,)= 13" 13" 13" <br /> Test End Time(T'r): 3:00 3:00 3:00 <br /> Final Reading(Rr): 13" 13" 13" <br /> Test Duration(Tr—TI): 1 Hour I]Flour 1 Hour <br /> Change in Reading(Rr—RJ: 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> T est Result:::. X <br /> Comments— include information on to airs made prior to testing,and recotrtmendeo <br /> d llow-u or ailed tests) <br /> CERTIFICATION OF TEC MCTAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the Information contained in this report is true,accurate,and be fedi compiimtce with legat requirements. <br /> Technician's Signature: Date-12/11/07 <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 />