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�� <br /> Spill Bucket Testing Report FormsWRCB,Janu (,1 4 2015 <br /> This form is intended Por use by contractorsperforming annual lasting of UST spill containment structures. The completed form and p q <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. I p E ANAL <br /> 1. FACILITY INFORMATION <br /> Facility Name: Rancho San Miguel Market Date of Testing:06/25/15 <br /> Facility Address: 1409 S.Airport Way Stockton,CA 95206- <br /> Facility Contact: Gilbert Silva (209)942-2840 <br /> Date Local Agency Was Notified of Testing: 6/19/15 <br /> Name of Local Agency Inspector (if present during testing): Fatima Zareef <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentialst: ❑X CSLB Contractor ® ICC Service Tech. ❑SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: © Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number,Stored Product etc.) 01 -Re u 02-Prem <br /> Bucket Installation Type: E] Direct Bury ❑ Direct Bury E] Direct Bury ❑ Direct Bury <br /> ©Contained in Sump Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter. 13.00 in. 13.00 In. <br /> Bucket Depth: 13.50 in. 13.00 in. <br /> Wait time between applying 10 min. 10 min. <br /> vacuumhvater and start of test: <br /> Test Start Time IT,): 1:15pm 1:15pm <br /> Initial Reading IN): 12.00 in. 12.00 in. <br /> Test End Time(TF): 2:15pm 2:15pm <br /> Final Reading(I#): 12.00 in. 12.00 in. <br /> Test Duration(TF-TI): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.000 in. 0.000 In. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: Pass ❑Fail ©Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail <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 certify that all the InfganaticIn coatalned in this report/s true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:06/25/15 <br /> t 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 />