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SWRCB , January 2006 <br /> Spill Bucket 'Testing Report Form <br /> This fibrin is intended for use by contractors penfbrnning annual testing of UST spill containnnent structures. The completed form annd <br /> printouts from tests (if applicable) , should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Fast & Easy Morada #60 (Stockton ) Date of Testing : 4/11 /19 <br /> Facility Address : 10878 N Highway 99 Stockton 95212 <br /> Facility Contact: Asim Phone : (707) 393-9859 <br /> Date Local Agency Was Notified of Testing : 3-21 - 19 <br /> Name of Local Agency Inspector (if present during testing) : Stacy Rivera <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : Confidence UST Services , Inc. <br /> Technician Conducting Test: Timothy Capehart <br /> Credentials ' : Q CSLB Contractor OICC Service Tech . SWRCB Tank Tester Other (Specify) <br /> License Number(s) : 804904 8414476 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : Lake Test I Equipment Resolution : 0 .0625" <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Premium- 1 Premium- 2 Unleaded Diesel <br /> tVumber, Stored Product, etc.) <br /> [Bucket Installation Type : ® Direct Bury ® Direct Bury Direct Bury ® Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump70.1 <br /> Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter : 11 . 0" 11 . 0" 11 . 0" 11 . 0" <br /> Bucket Depth : 11 . 0" 12. 5" 12. 5 12. 5 <br /> Wait time between applying <br /> 5 min 5 mins 5 mins 5 mins <br /> vacuum/water and start of test : <br /> Test Start Time ( Ti ) : 1 :30 1 :30 2 :30 1 :30 <br /> Initial Reading (Ri ) : 11 . 0" 12. 0" 12. 0" 12 . 0" <br /> Test End Time (TF ) : 2 :30 2 :30 3 :30 2 :30 <br /> Final Reading (RF ) : 11 . 5" 12. 0" 12 . 0" 12. 0" <br /> Test Duration (TF — Ti ) : 60 mins 60 mins 60 mins 60 mins <br /> Change in Reading (RF - R1 ) : 0 .5" 0. 0" 0 . 0" 0 . 0" <br /> Pass/Fail Threshold or <br /> 0 .0625" 0. 0625" 0 . 0625" 0 . 0625" <br /> Criteria : <br /> Test Result : ❑ Pass I Fail m Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and reconuznernded follow-zip for failed tests) <br /> The premium 1 opw fill spill bucket does not hold 5 gallons Due to being a direct buried opw spill bucket we will have to return and break concrete to <br /> make riser adjustments and replace the spill bucket and retest . Unleaded fill spill bucket failed hydrostatic test due to leaking fill cap retested with pass . <br /> I <br /> i <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 : Date : 4/11 /19 <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 /> I <br />