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S W RCB,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 farm 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 Names: Van De Pol I Date of Testing: 2/12/2018 <br /> Facility Address: 816 Frontage Rd Ripon,CA 95336 <br /> Facility Contact: Ted Van De Pol Phone: 209-649-8308 <br /> .,3 <br /> z <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Chris A. <br /> Credentials: ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 8230218 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure and H2O Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 Diesel 2 3 4 <br /> Number, Stored Product etc. <br /> Bucket Installation Type: Direct Bury X Direct Bury X Direct Bury ❑Direct Bury <br /> xContained in Sump D Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 13" <br /> Bucket Depth: 12" <br /> Wait time between applying 10 min <br /> vacuum/water and start of test: <br /> Test Start Time(T): 9:00 <br /> Initial Reading(Rt): 11.5" <br /> Test End Time(TF): 10:00 <br /> Final Reading(RF): 11.5" <br /> Test Duration(TF—Tj): 1 Hour <br /> Change in Reading(RF-Rj: No <br /> Pass/Fail Threshold or pass <br /> Criteria: <br /> Test Result: x Pass ❑Fail Pass ❑Fail Pass ❑Fail D 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 /> 1 hereby cerl�o that all the Information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature:V — Date: 2112/18 <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 />