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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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: San Joaquin Regional Transit District Date of Testing: 6/27&28/2011 <br /> Facility Address: 1533 E.Lindsay Street,Stockton,California,95205 <br /> Facility Contact: Don Nichols I Phone: (209)943-1111 <br /> Date Local Agency Was Notified of Testing: 6/13/2011 by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent during testing): Jeff Wong,REHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: ❑CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester D Other(Spec) <br /> License Number(s): 90-1120/1CC#5246802-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum D Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16"x 25' <br /> IdentifySpill Bucket(By Tank 1 Diesel 2 Diesel 3 Diesel 4 Diesel <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury X Direct Bury <br /> ❑Contained in Sump D Contained in Sump D Contained in Sum D Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 13 '/2" 13 '/2" 12" 13" <br /> Wait time between applying 5 Minutes 5 Minutes 5 Minutes 5 Minutes <br /> water and start of test: <br /> Test Start Time(Tj): 10:40 10:45 10:50 10:55 <br /> Initial Reading(110: 12" 12" 11" 12" <br /> Test End Time(TF): 11:40 11:45 11:50 11:55 <br /> Final Reading(RF): 12" 12" 11" 12" <br /> Test Duration(TF—TO: 60 Minutes 60 Minutes 60 Minutes 60 Minutes <br /> Change in Reading(RF-Ri): 0" 0" 0" 0" <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: I X Pass Fail X Pass Fail X Pass Fail X Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommendedfollow-upforfailed tests) <br /> Test Fluid supplied and recovered for reuse by, R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 7 hereby certify that all the information containedin this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 6/27&28/2011 <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 />