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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: Valley Pacific I Date of Testing: 03/09/17 <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: 02/27117 @2:34pm via email <br />Name of Local Agency Inspector (if present during testing): <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 (Specify) <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 (Specify) <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: +or -1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />T-1 Diesel Fill <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />131/2" <br />Wait time between applying <br />vacuum/water and start of test: <br />10min <br />— <br />Test Start Time (Tj): <br />1:30pm <br />Initial Reading (Rj): <br />131/2" <br />Test End Time (TF): <br />2:30pm <br />M A 2U, 2017 <br />Final Reading (RF): <br />131/2" <br />Test Duration (TF — TI): <br />15min <br />ENINIMONN ALTH <br />Change in Reading (RF - RI): <br />0" <br />Pass/Fail Threshold or Criteria: <br />+or -0.002" <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and reccomirlen(led follow-up for failed tests) <br />1. Replaced leaking drain valve. <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: K-11 Date: 03109117 <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 />