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ICIA& <br />Spill Bucket Testing Report Form ENV <br />This form is intended for use All contractors performing annuattesting of USTspIllcontainment structures. The completed farm W1 <br />tests (if applicable), should be provided to the facility ownerloperatorforsubmittal to the localregulatoryagencY <br />1. FACILITY INFORMATION, <br />Facility Name: Shell 1-5 Date ofTesting: 3/5/' <br />Facility Address: 717 W Eighth St., Stockton, Ca. 95206 Phone: 209-939-0961 <br />Facility Contact Owner -Joe <br />Name of Local Agency Inspector (if present during testingi. Michelle Henry <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Jeff Conger SWRCB Tank Tester Other (Specify) <br />Credentials CSLB Contractor ICC S-ervice-'7ech. <br />License Number(s): ICC# 1081782 -UT SWRCB# 90-1116 CSL13# 894932 <br />3. SPILL BUCKET TESTING INFORMATION <br />est Method Used: <br />01-lydrostatic <br />Vacuum <br />M fat <br />Test Equipment Used: pe Measure-, Stop Watch <br />Equipment Resolution: 1/16" <br />#2 -Premium <br />Buckefl—nstallation Type: <br />Direct BuNQUMp <br />Bucket Diameter: <br />Bucket Depth: <br />inal Reading <br />Test End Time (TF): <br />li: Final Reading (RF): <br />TF <br />Test Duration Ti): J <br />60 min S <br />Change in Reading (RF - Ri): <br />Pass/Fail Threshold or Criteria: <br />mins <br />60 • <br />(inctude information 017. 6170OU ANIVIN—Af — — <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />hereby cerW that all the information contain in this mport is lirue, accurate, and in full compliance wth legal <br />Technician's Signature* Date: 3/5/2015 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor- However, local requirement <br />stringent. <br />may be more <br />