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1. .f KLL;WVLU NOV 2 3 2015 ENVIRONMENTAL SWRCB. , aFUfVMCRcoAD7uIa%I_ Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility ownerfoperator for submittal to the local regulatory agency. 1 FAtal ITV INIF11RMATICIN Facndy Name' Rancho San Miguel Data of Testing: 10/26/15 Facility Address: 610 S. Cherokee Ln. Lodi, CA 95240 - Facility Contact: Jesus Jurado (209) 339-8200 Date Local Agency Was Notified of Testing: 10/14/15 Name of Local Agency Inspector (if present during testing)Aris Velos0 Company Name Service Station Sys Technician Conducting Test: Kris Bell Credentialst: Q CSLB Contractor License Number(s). License:485184 2. TESTING CONTRACTOR INFORMATION ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other ICC:5297793-UT I CRII I RI ICKFT TFSTINR INFnRMATInN Test Method Used. ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used Measuring Tape Equipment Resolution 1/16 in. Identify Spill Bucket (By Tank Number. Stored product. etc.) 1 Fill Bucket 01 - Re a 2 Fill Bucket 02 - Prem 3 4 Bucket Installation Type: ❑ Direct Bury ❑Q Contained in Sump ❑ Direct Bury ®Contained in Sump ❑ Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑Contained in Sump Bucket Diameter: 13.00 In. 13.00 In. Bucket Depth: 13.50 in. 13.00 in. Wart time between applying vacuumiwater and start of test: 10 min. 10 min. Test Start Time (T, ): 9:20am 9:20am Initial Reading (R, ): 12.56 in. 12.00 In. Test End Time (TF ): 10:20am 10:20am Final Reading (RF ): 12.56 in. 12.00 in. Test Duration (TF -T,): 1.00 hr. 1.00 hr. Change in Reading (RF - R, ): 0.000 in. 0.000 in. Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS Test Result: ® Pass ❑ Fail ® Pass ❑ Fad ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the infer coglained in this report Is true, accurate,and In full compliance with legal requirements. Technician's Data 10/26/15 t State laws and regulations do not currently require testing to be performed by a qualified contractor. Howeverlocal requirements may be more stringent.