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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing aminal 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: GEMCO I Date of Testing: <br /> Facility Address: 1022 FRONTAGE ROAD,RIPON,CA 95366 <br /> Facility Contact: JOHAL Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifresent during testing): ELENA MANZO ' rTr�•" �• <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: KAISER COMMERCIAL PETROLEUM <br /> Technician Conducting Test: GREG KAISER <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): CSLB No.859535,ICC No.5252318 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: TAPE MEASURE,H2O Equipment Resolution: 1/32 <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) REG.87 PREM.91 <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury 0 Direct Bury 0 Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 14 14 <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 9:10 9:10 <br /> Initial Reading(RO: 12% 13" <br /> Test End Time(TF): 10:10 10:10 <br /> Final Reading(RF): 121/2 13" <br /> Test Duration(TF—Tj): 1 HOUR I HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or PASS PASS <br /> Criteria: <br /> Test Result: ® Pass 0 Fail ® Pass 0 Fail 0 Pass 0 Fail 0 Pass ❑Feil <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Test water sunnlied by KCP <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contain B in this report Is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: 1A Date: 3/17/2016 <br /> ' State laws and regulations don currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />