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0 <br /> RECEMED <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The t and <br /> printouts from tests (f 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: 3/12/2015 A111 i" <br /> Facility Address: 1501 W CHARTER WAY, STOCKTON, CA 95206 <br /> Facility Contact: MIKE ELIASON Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: 314115 <br /> Name 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: RICHARD THOMAS <br /> Credentials': ®CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705(CSLB Contractor)—5254736-UT(ICC Service Tech.)—06-1672(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other(Spec) <br /> Test Equipment Used VISUAL TAPE MEASURE Equipment Resolution 1/16" <br /> N s <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: 12" 12" <br /> Bucket Depth: 13.75" 13.25" <br /> Wait time between applying 10 MIN 10 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 9:00 9:00 <br /> Initial Reading(R,): 12.25" 11.75" <br /> Test End Time(TF): 10:00 10:00 <br /> Final Reading(RF): 12.25" 11.75: <br /> Test Duration(TF—Ti): 1 HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or Criteria: NO LOSS NO LOSS NO LOSS NO LOSS <br /> Test Result: ® Pass ❑Fail, 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: 14-5 Date: 3/1212015 <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 />