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.......... .. <br /> 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(zf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 76 Country Side Mini Mart _ Date of Testing: 5-17-2010 <br /> Facility Address: 14971 N HWY 88 <br /> Facility Contact: Bic Phone: 209-968-8553 <br /> Date Local Agency Was Notified of Testing: 5-13-2010 <br /> Name of Local Agency Inspector(f present during testing): Tony On Site <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-SERVICE STATION TESTING <br /> Technician Conducting Test: HEATH MCEVER <br /> Credentials': ❑CSLB Contractor ❑ICC Service Tech. X SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 04-1677 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:WATER <br /> Equipment Resolution:INCHES <br /> ::. .:. ..�_ <br /> Identify Spill Bucket(By Tank 187 2 gl 3 Diesel <br /> 4 <br /> Number,Stored Product, etc.) <br /> Bury X Direct <br /> Bucket Installation Type: X Direct BBury X Direct Bury El Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 in 11 in 11 in <br /> Bucket Depth: 13 in 13in 13 in <br /> Wait time between applying <br /> vacuum/water and start of test: 5 Min 5 Min 5 Min <br /> Test Start Time(T,): 12:50 12:50 12:50 <br /> Initial Reading(R,): 9 7/8 in 10.25 in 10 in <br /> Test End Time(TF): 13:50 13:50 13:50 <br /> Final Reading(RF): 12 In 12 In 3 in <br /> Test Duration(TF—Ti): 1 Hour I Hour I Hour <br /> Change in Reading(RF-RI): 0 0 -3 <br /> Pass/Fail Threshold or <br /> Criteria: 0 0 0 <br /> Test Result: X Pass ❑Fail X Pass ❑Fail ❑ Pass X Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow up for failed tests) <br /> Bucket Removed and Replaced By contractor. A--—n-nular snace test to be re rmed <br /> PER INSPECTORS REQUEST <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 /> Technician's Signature: Date: <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 />