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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 spill containment structures. The completed.form 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: CRUISERS MANTECA BP29 Date of Testing: 9/25/16 <br /> Facility Address: 1137 W LATHROP <br /> Facility Contact: MANICA Phone: 209-824-2760 <br /> Date Local Agency Was Notified of Testing: NA <br /> Name of Local Agency Inspector(f present during testing) ELANA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: GABRIEL VENEGAS <br /> Credentials': ❑CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:WATER Equipment Resolution:TAP <br /> Identify Spill Bucket(By Tank l 87 2 91 3 DSL 4 <br /> Number,Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury C Direct Bury <br /> X Contained in Sump X Contained in Sump Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13" 13" 13" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 130 PM 130 PM 130 PM <br /> Initial Reading(111): 14" 15" 14'/4" <br /> Test End Time(TF): 230 PM 230 PM 230 PM <br /> Final Reading(RF): 14" 15" 14'/4" <br /> Test Duration(TF—Ti): IHR 1 HR IHR <br /> Change in Reading(RF-Rj): NONE NONE NONE <br /> Pass/Fail Threshold or NONE NONE NONE <br /> Criteria: <br /> Tes't'R suit X Pass. -CJ-Fa�1 X Pass. ..l ;Fay!, X':Pass '. Bail Puss 0 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 the port is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: <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 />