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0 <br /> SWRCB,January 2006 <br /> PINNACLE Spill Bucket Testing Report Form <br /> This form/s intended foruse bycontmctors pedormfng annual testing of UST spill containment structures. The completed form and printouts from <br /> tests(ifsppl/cable),should be provided to the facility owner/operatorforsubmittal to the local mgulatoryagency <br /> 1. FACILITY INFORMATION <br /> Facility Name: Shell 1-5 1Date of Testing: 3/5/2014 <br /> Facility Address: 717 W Eighth St., Stockton, Ca. 95206 <br /> Facility contact: Owner IPhone: 209-939-0961 <br /> Nameof Local Agency Inspector(ifpresentdunnglesting). Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Pinnacle Fuel Compliance Services, Inc. <br /> Technician Conducting Test: Jeff Conger <br /> credentials': N CSLB Contractor N ICC Service Tech. ®SWRCB Tank Tester ❑Other(Specify,) <br /> License Number(s): ICC# 1081782-UT SWRCB#90-1116 CSLB#894932 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: NHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure,Stop Watch Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank LL <br /> Number, Stored Product, etc.) #1-Regular #2-Premium #3-Diesel <br /> Bucket Installation Type: Sump Sump Sump <br /> Direct Bu /Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 15" 15" 15" <br /> Wait time between applying 10 mins 10 mins 10 mins <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 09:40 09:40 09:40 <br /> Initial Reading(RI): 12 11/16" 13 1/2" 13 7/8" <br /> Test End Time(TF): 10:40 10:40 10:40 <br /> Final Reading(RF): 12 11/16" 13 1/2" 13 7/8" <br /> Test Duration (TF-TI): 60 mins 60 mins 60 mins <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 1/8"-60 mins 1/8"-60 mins 1/8"-60 mins <br /> Test Result: Pass/Fail PASS I PASS I PASS <br /> Comments-(include information on repairs made priorto testing,and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> /hereby cedffy that aiithe inforrnartionn/contafned fn this report is true,accurate, and in full compliance with legal requirements. <br /> Technician's Signature: �l�J Date:3/5/2014 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more <br /> stringent. <br />