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EVEIVEL <br /> JUL 01 2015 <br /> • SWRCB,January 2006 <br /> Spill Bucket Testing Report,F.mrrm iMENTAI <br /> This form is intended for use by contractors pedorming annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility owneM 'n for for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Rancho San Miguel Market Date of Testing:6/5/14 <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: 5/27/14 <br /> Name of Local Agency Inspector (ifpresent during testing): Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentialsi: ❑X CSLB Contractor ❑X 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: ❑X Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 In. <br /> Identify SpillBucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number, Stored Product,etc.) 01 Re u 02 Prem <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> 0 Contained in Sump © Contained in Sump ❑ Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 14.00 in. 13.00 in. <br /> Wait time between applying <br /> vacuumtwater and start of test: 5 min. 5 min. <br /> Test Start Time IT,): 1:13pm 1:13pm <br /> Initial Reading(R, ): 13.000 in. 11.500 in. <br /> Test End Time(TF): 2:13pm 2:13pm <br /> Final Reading(RF): 13.000 in. 11.500 in. <br /> as Duration(TF-T 1): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.0000 in. 0.0000 In. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ❑x Pass ❑ Fail ❑X 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 information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> • Technician's Signature: Data:6/5/14 <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 />