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09/22/2010 10:28 209-465-488 HMC HENDERSON MALNT PAGE 09/11 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containm838ent structures. The completed form <br /> and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory <br /> agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TEXACO Date of Testing: 6/222010 <br /> Facility Address: 1405 CALIFORNIA ST,ESCALON,CA,95320 <br /> Facility Contact: CHOCO I Phone: 209-838-7674 <br /> Date Local Agency Was Notified of Testing: 6-17-10 <br /> Name of Local Agency Inspector(lf present during testing): Twee <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-SERVICE STATION TESTING <br /> Technician Conducting Test: HEATH MCEVER <br /> Credentials': 0 CSLB Contractor O ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 04-1677 <br /> 3- SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: _ _JkHydrostatic 0 Vacuum O Other <br /> Test Equipment Used: WATER EquipmentResolution: INCHES <br /> " <br /> Identify Spill BucketTa <br /> (By nk 187 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: OrDirectBury ODirect Bury ADirect Bury G Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump a Contained in Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 0940 0940 0940 <br /> Initial Reading(&): 12" 12" 13'/2" <br /> Test End Time(Tr): 1040 1040 1040 <br /> Final Reading(R,): 1T, 12" 13 %a" <br /> Test Duration(Tr-Ti): IHR 1 HR 1 HR <br /> Change in Reading(Rr-RD: 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria <br /> Test Result: ass. O Fail Pass OyF" At Pass ,II Fail,'; 0 Pass 0 Fail ; <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for ailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all 1/1e information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> hi/ is/ <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 />