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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(if applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SOUTH BAY TIRE Date of Testing: 312012012 <br /> r <br /> ility Address: 1501 W. CHARTER WAY, STOCKTON, CA 95206 <br /> ility Contact: Phone: (209)948-9412 <br /> e Local Agency Was Notified of Testing: 311412012 <br /> me of Local Agency Inspector(if present during testing): NONE PRESENT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705(CSLB Contractor)—1048103-UT(ICC Service Tech.)—90-1200(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other(Spec) <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1116" <br /> s Aa a <br /> z <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 87 FILL DIESEL FILL <br /> Bucket Installation Type: ® Direct Bury ®Direct Bury ❑ Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11.50" 11.50" <br /> Bucket Depth: 14.00" 14.00" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12:15 PM 12:15 PM <br /> Initial Reading(RI): 12.50" 12.50" <br /> Test End Time(TF): 1:15 PM 1:15 PM <br /> Final Reading(RF): 12.50" 12.50" <br /> Test Duration(TF—TI): 1 HR 1 HR <br /> Change in Reading(RF-RI): 0" 0" <br /> Pass/Fail Threshold or Criteria: 1/16" 1116" <br /> Test Result: Z Pass ❑Fail N Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up 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 /> Technician's Signature: " /" ;-- Date: 312012012 <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 />