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SWRCB,January 200G <br /> t,r <br /> ® a t e <br /> 4 <br /> Spill Bucket Testing Report Form rA <br /> This form is intended for use by contractors performing annual testing of UST spilt containment structures. The completed form and printouts from <br /> tests(if applicable),should be pro vided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Shell 1-5 1 Date of Testing: 3/29/2017 <br /> Facility Address: 717 W Eighth St., Stockton, Ca. 95206 <br /> Facility contact: Owner-Joe I Phone: 209-939-0961 <br /> Name of Local Agency Inspector(if present duringtestingf Inspector on site <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Pinnacle Fuel Compliance Services, Inc. <br /> Technician Conducting Test: Jeff Conger <br /> Credentials: ® CSLB Contractor ® ICC Service Tech. ®SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): ICC# 1081782-UT SWRCB#90-1116 CSLB#894932 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure,Stop Watch Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number Stored Product, etc. #1-Regular #2-Premium #3-Diesel <br /> Bucket Installation Type: Sump Sump Sump <br /> Direct Bur /Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13 1/2" 14 1/4" 141/2" <br /> Wait time between applying 10 mins 10 mins 10 mins <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 09:26 09:26 09:26 <br /> Initial Reading(RI): 13" 13 3/8" 14" <br /> Test End Time(TF): 10:26 10:26 10:26 <br /> Final Reading(RF): 12 3/8" 13 3/8" 14" <br /> Test Duration(TF-T,): 60 mins 60 mins 60 mins <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 1/8"-60 mins 1/8"-60 mins 1/8"-60 mins <br /> Test Result: Pass/Fail FAIL PASS PASS <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> Note that the Regular spill FAILED due to defective,leaking fill swivel adaptor. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> /hereby cer ify that a//the information contained in this repott is true,accurate,and in fu//compliance with legal requirements. <br /> Technician's Signature: Date:3/29/2017 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more <br /> stringent. <br />