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0 • SWRCB,January 2006 <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(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 4. FACILITY INFORMATION <br /> Facility Name: TOWER MART#876 1 Date of Testing: APR 23, 2008 <br /> Facility Address: 14000 E. HWY 88, LOCKEFORD, CA 95237 <br /> Facility Contact: MOHAMMAD AFZAL Phone: (209)727-5442 <br /> Date Local Agency Was Notified of Testing: APR 3, 2008 <br /> Name of Local Agency Inspector('(present during testing): ARIS CACAPIT <br /> 5. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials': N CSLB Contractor E ICC Service Tech. N SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705(CSLB Contractor) -- 1048103-UT(ICC Service Tech.) -- 90-1200 (SWRCB Tank Tester) <br /> 6. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other(Spec) <br /> Test Equipment Used:VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) DIESEL FILL <br /> Bucket Installation Type: N Direct Bury ❑Direct Bury ❑ Direct Bury ❑Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11.50" <br /> Bucket Depth: 13.50" <br /> Wait time between applying 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 9:00 AM <br /> Initial Reading(RI): 12.00" <br /> Test End Time(TF): 10:00 AM <br /> Final Reading(RF): 10.00" <br /> Test Duration(TF—Tj): 1 HR <br /> Change in Reading(RF-Rj): -2.00" <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: ❑ Pass E 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 information contained in this report is true,accurate, and in full compliance with legal requirements. <br /> Date: APR 23, 2008 <br /> Technician's Signature: �- <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 />