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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 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 Date of Testing: 3-4-2013 <br />Facility Address: 717 W. Eighth Street Stockton <br />Facility Contact: Joe Dan Tran Phone: 209-939-0961 <br />Name of Local Agency Inspector (ifpresentduring testing): Inspector Aris Cacapit <br />2_ TESTING CONTRACTOR INFORMATION <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Aneil Chand <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑Other (Specify) <br />License Number(s): ICC# 5119959 -UT SWRCB# 90-1262 CSLB# 894932 <br />3_ SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br />Test Equipment Used: Tape measure, stop watch <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Regular Fill Super Fill <br />Diesel <br />Bucket Installation Type: <br />Direct Bu /Sum <br />Sump Sump <br />Sump <br />Bucket Diameter: <br />12 12 <br />12 <br />Bucket Depth: <br />14 14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />15 15 <br />15 <br />Test Start Time (TI): <br />60mins 60mins <br />60mins <br />Initial Reading (RI): <br />9" 9" <br />9" <br />Test End Time (TF): <br />0 mins 0 mins <br />Omins <br />Final Reading (RF): <br />91, 91, <br />91, <br />Test Duration (TF - TI): <br />60 mins 60 mins <br />60 mins <br />Change in Reading (RF -RI): <br />0 0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />1/16-60 1/16-60 <br />1/16-60 <br />Test Result: Pass/Fail <br />PASS PASS <br />PASS <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 />/ hereby cert/fy that al/ the information contained in this report is true, accurate, and in fu// comp/lance with legal requirements. <br />Technician's Signature: Date: 3-4-2013 <br />I 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 />