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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> A g A <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 local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TOWER MART#876 1 Date of Testing: APR 23,2008 <br /> 2 <br /> Facility Address: 14000 E. HWY 88, LOCKEFORD, CA 95237 <br /> Facility Contact: MOHAMMAD AFZAL I Phone: (209)727-5442 <br /> Date Local Agency Was Notified of Testing: APR 3, 2008 <br /> Name of Local Agency Inspector(:fpresent during testing): ARIS CACAPIT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials: E CSLB Contractor E ICC Service Tech. E SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705(CSLB Contractor) -- 1048103-UT(ICC Service Tech.) -- 90-1200(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other(Specify) <br /> Test Equipment Used: VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc) 87 FILL 87 VAPOR 91 FILL 91 VAPOR <br /> Bucket Installation Type: E Direct Bury E Direct Bury E Direct Bury E Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11.50" 11.50" 11.50" 11.50" <br /> Bucket Depth: 15.00" 14.00" 14.50" 14.50" <br /> Wait time between applying 0 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 9:00 AM 9:00 AM 9:00 AM 9:00 AM <br /> Initial Reading(Ri): 13.50" 12.50" 13.00" 13.00" <br /> Test End Time(TF): 10:00 AM 10:00 AM 10:00 AM 10:00 AM <br /> Final Reading(RF): 13.50" 12.50" 13.00" 13.00" <br /> Test Duration(TF—Tt): 1 HR 1 HR 1 HR 1 HR <br /> Change in Reading(RF-Rt): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: E Pass ❑Fail E Pass [:]Fail E Pass ❑ Fail E 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: � �� ` Date: APR 23, 2008 <br /> 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 />