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ru. nox vtua <br /> tx <br /> Sonora CA 95370 <br /> Ca: 623541 A-Haz <br /> lite ch <br /> Phone: 209-532-7320 <br /> Compliance without compromise Fax: 209-533-2650 <br /> mail agalltechpetro.com <br /> Vap Dr S d1l Bucket Testing Report Form www. alltechpeYro. com <br /> 1 . FACILITY INFORMATION <br /> Facility Name: Costo # 1091 Lodi Date of Testing : 05/17/17 <br /> Facility Address : 2680 Reynolds Ranch Rd . <br /> Facility Contact : Rick Medeiros Phone: 209 -366-7332 <br /> Date Local Agency Was Notified of Testing : 04/24/17 <br /> Name of Local Agency Inspector (if present during testing): Cesar Ruvalcaba cruvalcaba@sjcehd . com <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc, P .O . Box 4208, Sonora CA 95370 . 209) 532 -7320 <br /> Technician Conducting Test: Isaac Anderson <br /> Credentials ® CSLB Contractor ® ICC Service Tech . ® SWRCB Tank Tester ❑ Other (Specify) <br /> License #(s) : CA 623541 A-HAZ ICC - 8146912-UT SWRCB 09- 1749 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used : One Hour observed test Equipment Resolution : 1 /16" <br />! Identify Spill Bucket (By 1 87A Vapor 2 87B Vapor 391 Vapor 4 Additive Aux <br /> Tank Number, Stored <br />( Product, etc. <br /> Bucket installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® in Sump ® In Sump ® In Sump ® In Sump <br /> Wait time between <br /> applying vacuum/water 0 0 0 0 <br /> and start of test: <br /> Test Start Time (Ti) : 9 : 00 am 9 : 00 am 9 :00 am 9 . 00 am <br /> Initial Reading (R,) : Top of cap Top of cap Top of cap Top of cap <br /> Test End Time (TF) : 10: 00 am 10 : 00 am 10 : 00 am 10 :00 am <br /> Final Reading ( RF) . Top of cap Top of cap Top of cap Top of cap <br /> Test Duration (TF — T,) : 1 . 0 hr 1 . 0 hr 1 . 0 hr 1 . 0 hr <br /> Change in Reading (RF - R,) : 0 . 0 0 . 0 0 . 0 0 . 0 <br /> Pass/Fail Threshold or 1 /16 1 /16 1 /16 1 /16" <br /> Criteria : <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 <br /> tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the information contained in this report is true, accurate, and in full compliance with <br /> legal requirements. <br /> f. <br /> TechnicianDate: 05/17/17 <br />