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SWRCB,January 2008 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the focal 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 /> F=acility Contact: Gilbert Silva (209) 942-28.40 <br /> Date Local Agency Was Notified of Testing: 5/27/14 <br /> Name of Local Agency Inspector (if present during testing): Stacy Rivera <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Narne:Senlice Station Systems <br /> Technician Conducting Test.: Iris Bell <br /> Credentialst: ❑X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester [:] Other(Specify) <br /> License Number(s): License:4$5184 ICC:5297793-UT <br /> 3, SPILL BUCKET TESTING INFORMATION <br /> Test Method U ed: Q 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 Producl, etc.) 01 Re u 02 Prem <br /> Installation <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket InstalEatian Type: <br /> Contained in Sump ® Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diamete. 13.00 in. 13.00 in. <br /> Bucket Depth: 14.00 in. 13.00 in. <br /> Wait time between applying 5 mitt, 5 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti ): 1:13pm 1:13pm <br /> Initial Reading(Ri ): 13.000 in. 11.500 in. <br /> Test End Time(Tr): 2:13pm 2:13pm <br /> Final Reading(PF): 13.000 in. 11.500 in. <br /> Test Duration(TF-T i); 1.00 hr. 1.00 hr. T <br /> Change in Reading(RF -Ro): 0.0000 in. 0.0000 In. "it - <br /> Pass/Fail Threshold or Criteria ZERO LOSS ZERO LOSS <br /> Test Result: ® Pass ❑ Fail ® Pass [-IFail ❑ Puss s E] Fail <br /> Comments Include information on repairs made prior to testing,and recomEFMV6Vpyj_I�Rf�orr faIL iled tests.�� <br /> i� tiDE'�PARfI`�,I!ITMEN1 <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: Date: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 />