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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 />4 FACiI ITY INFORMATION <br />Z. TESTING CONTRACTOR INFORMATION �tvvtt<un��ENT <br />Company Name: Service Station Systems... I`jt/SERWCES <br />Technician Conducting Test: Kris Bell <br />Credentialsi: CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑ other (Specify) <br />License Number(s): License: 485184 ICC:8833000 <br />SPII I Rl ICKF7 TESTING INFORMATION <br />Test Method Used: ❑X Hydrostatic ❑Vacuum ❑Other <br />Facility Name: Shell/Tesoro <br />M-1 OWN no V183 <br />Facility Contact: Guillermo Lopez (209) 727wO823 <br />Date Local. • • of Testing: 7/24118 <br />Name of - Barker <br />Z. TESTING CONTRACTOR INFORMATION �tvvtt<un��ENT <br />Company Name: Service Station Systems... I`jt/SERWCES <br />Technician Conducting Test: Kris Bell <br />Credentialsi: CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑ other (Specify) <br />License Number(s): License: 485184 ICC:8833000 <br />SPII I Rl ICKF7 TESTING INFORMATION <br />Comments: Replaced DSL Bucket ORing <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />!hereby certify that all fhe lnf�outtaiilL cor�alned in this report is true, accurate,and In full compl/ance w/th legal raqulrements. <br />Technician's S <br />Date 08/28/18 <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 />Test Method Used: ❑X Hydrostatic ❑Vacuum ❑Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:1/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />02 - Prem <br />3 Fill Bucket <br />03 - Diesel <br />4 <br />❑ Direct Bury <br />❑X Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑X Contained in Sump <br />E]Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13,00 in. <br />Bucket Depth: <br />15.00 in. <br />14.00 in. <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test Stan Time (T, ): <br />9:50am <br />9:50am <br />9:55am <br />Initial Reading (RI ): <br />13.750 in. <br />13.375 in. <br />13.625 in. <br />Test End Time (TF): <br />10:50am <br />10:50am <br />10:55am <br />Final Reading (RF ): <br />13.750 in. <br />13.375 in. <br />13.625 in. <br />Test Duration (TF -T1): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - Ri ): <br />0.0000 In. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test. Result: <br />Q Pass ❑ Fail <br />Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments: Replaced DSL Bucket ORing <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />!hereby certify that all fhe lnf�outtaiilL cor�alned in this report is true, accurate,and In full compl/ance w/th legal raqulrements. <br />Technician's S <br />Date 08/28/18 <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 />