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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: Texaco I Date of Testing: 7-15-08 <br /> Facility Address: 1405 California St,Escalon CA 95320 <br /> Facility Contact: Donna Phone: 209-499-2693 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): Munny <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: INC-Henderson Maint Co <br /> Technician Conducting Test: Gavin Williams/Joe Bridges <br /> Credentials: 0 CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 5285969-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Water Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 T-1 UNL 2 T-2 Super 3 T-3 Diesel 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury XDirect Bury X Direct Bury 0 Direct Bury <br /> ❑Contained in Sump 0 Contained in Sump 0 Contained m Sump 0 Contained m Sum <br /> Bucket Diameter: 11" I1" 11" <br /> Bucket Depth: 12 3/." 13 %." 14" <br /> Wait time between applying I Hr 1 Hr 1 Hr <br /> vacuum/water and start of test: <br /> Test Start Time(T): 2:00p 2:00p 2:00p <br /> Initial Reading(111): 9'/," 9%11 12'/4" <br /> Test End Time(TF): 3:00p 3:00p 3:00p <br /> Final Reading(RF): Same Same Same <br /> Test Duration(TF—Tj): 1 Hr I Hr 1 Hr <br /> Change in Reading(RF-Rj): None None None <br /> Pass/Fail Threshold or Pass Pass Pass <br /> Criteria: <br /> Test Result: X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-up forfailed 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 jullcompliance with legal requirements <br /> Technician's Signature: A� /� Date: 7-15-08 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />