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SWRCB , January 2006 <br /> Spill Bucket Testing Deport Form <br /> This form is intended for use by contractors peuforming annual testing of UST spill containment structures, The completed foruu and <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 0 ICC Service Tech . SWRCB Tank Tester Other (Specie) <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 Equipment Resolution : 0 .0625° <br /> Identify Spill Bucket (By Tank 1 2 3 } <br /> Number, Stored Product, etc) <br /> Bucket Installation Type : ® Direct Bury ® Direct Bury ® Direct Bury ® Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter : <br /> Bucket Depth : <br /> Wait time between applying <br /> vacuum/water and start of test : <br /> Test Start Time (Ti ) : <br /> Initial Reading (Ri ) : <br /> Test End Time (TF ) : <br /> Final Reading (RF ) : <br /> Test Duration ( TF — TI ) : <br /> Change in Reading (RF - Rj ) : <br /> Pass/Fail Threshold or <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 tests) <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 fall 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 />