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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 shwctur•es. The completed form and <br /> printouts from tests (f applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Valley Pacific Petroleum Date of Testing : 01 /16/18 <br /> Facility Address : 1524 Fresno Ave . , Stockton , CA 95206 <br /> Facility Contact : Mike Eliason Phone : (209)993-8793 <br /> Date Local Agency Was Notified of Testing : 01 /04/18 via email <br /> Name of Local Agency Inspector (rfpresent dining testing) : Betty Ho @ San Joaquin E . H . D . <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : CGRS , Inc . <br /> Technician Conducting Test : RICHARD THOMAS <br /> Credentials ' : ® CSLB Contractor ® ICC Service Tech . ® SWRCB Tank Tester ❑ Other (Sped) <br /> License Number(s) : 803616 (CSLB Contractor) -- 5254736 ( ICC Service Tech . ) -- 06-1672 (SWRCB Tank Tester) <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br /> Test Equipment Used : Tape Measure Equipment Resolution : +or-1 /16" <br /> Identify Spill Bucket (By Tank T-I Diesel Fill —T <br /> Number, Stored Product, <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: 12" <br /> Bucket Depth : 13112" <br /> Wait time between applying 10min <br /> vacuum/water and start of test: <br /> Test Start Time (Ti) : 9 : 00am <br /> Initial Reading (RI) : 131 /2" <br /> Test End Time (TF) : 10 : 00am <br /> Final Reading (RF) : 131 /2" <br /> Test Duration (TF — Tj) : 15min <br /> Change in Reading (RF - RI) : 0" <br /> Pass/Fail Threshold or Criteria : +or-0.002" <br /> Test Result. ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass [:] Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended folloi>>-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 trace, accurate, and in fill compliance with legal requirements. <br /> KAPA,Technician ' s Signature : Date : 01 /16/18 <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 />