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9 <br /> SWRCB,January 2006 <br /> y 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 /> 1. FACILITY INFORMATION <br /> Facility Name: TIME OIL#04-049 Date of Testing: APR 3, 2007 <br /> Facility Address: 14000 E. HWY 88, LOCKEFORD, CA 95237 <br /> Facility Contact: CHUCK SOFTICH I Phone: 800-426-0235 <br /> Date Local Agency Was Notified of Testing: MAR 20,2007 <br /> Name of Local Agency Inspector(ifpresent during testing): WILLIE NG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: ROB NEIMEYER <br /> Credentials: Z CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 803705 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑Vacuum ❑ Other(Specify) <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank. <br /> Number, Stared Product, etc.) =REGULARL. REGULAR VAPOR SUPER FILL SUPER VAPOR <br /> Bucket Installation Type: ® Direct Bury E Direct Bury Z Direct Bury ® Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 10.50" 10.50" 10.50" 10.50" <br /> Bucket Depth: 12.00' 12.00° 12.00' 12.00" <br /> Wait time between applying 0 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 9:00 AM 9:00 AM 9:00 AM 9:00 AAA <br /> Initial Reading(Rj): 12.00" 12.00" 12.00" 12.00" <br /> Test End Time(TF): 9.30 AM 9:30 AM 9:30 AM 9:30 AM <br /> Final Reading(RF): 12.00" 12.00" 12.00" 12.00" <br /> Test Duration(TF—Ti): 30 MIN 30 MIN 30 MIN 30 MIN <br /> Change in Reading(RF-RO: 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: I ® Pass ❑Fail ❑ Pass ❑ Fail Z Pass ❑ Fail Z 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 3,2007 <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 />