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09/22/2010 10:28 209-465-4988 HMC HENDERSON MAINT PAGE 11/11 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of UST spill containm838ent structures. The completed form <br /> and printouts from tests(#applicable),should be provided to the facility owner/uperator fur submittal to the local regulatory <br /> agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TEXACODate of Te 6/22/2010 <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(ifpresent during testing): Twee <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com y Name: SST-SERVICE STATION TESTING <br /> Technician Conducting Test: HEATH MCEVER C <br /> Credentials': 0 CSLB Contractor &16CServiceTe& 2fWRCBTimkTester 0 Other(Spec) <br /> LicenseNumber(s): 04-1677 $0162 g/,([ <br /> 3. SPH L BUCKET TESTING INFORMATION <br /> Test Method Used: Ptlydrostatic 0 Vacuum 0 Other <br /> 'lest Equipment Used: WATER Equipment Resolution: INCHES <br /> Identify Spill Bucket(By Tank 187 2 91 3 DSL 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury <br /> ❑Contained in Sump 0 Contained in Sump 0 Contained in Sum 0 Contained in Sump <br /> Bucket Diameter: I 1 i l 11 <br /> Bucket Depth: 13 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T): 0940 0940 0940 <br /> Initial Reading(Ril: I2" 12" 13 VT <br /> Test End Time(TF): 1040 1040 1040 <br /> Final Reading(RF): 12" 12" 13 %2" <br /> Test Duration(Tr-Til: I HR IBR. i HR <br /> Change in Reading(RF-Ril: 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> TestResoM 8'Yass', O Fail O Fal nss D Fail II Pass 0 Fal- <br /> Comments—(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby car*that all the information contained in this report is true,accurate,and infaAcompliance wide legal requiremena. <br /> Technician's Signature: ii Date / <br /> State laws and regulations do not urrently/require testing to be performed by a qualified contractor.However,local requirements <br /> moan ho morn efrinnnnt <br />