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0 0 <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <br />This form is intendedfor 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 ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Fast N Easy Date of Testing: 01-24-2011 <br />Facility Address: 10879 N. Hwy 99 <br />Facility Contact: BilalPhone: 209-931-6154 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rf present during testing): a Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Reliable Petroleum Services Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': x CSLB Contractor x ICC Service Tech. ® SWRCB Tank Tester 0 Other (Specify) <br />License Number(s): 883706 5250451 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank 1 T1: 91 Fill W <br />Number, Stored Product, etc.) <br />2 T2: 89 Fill -7 <br />3 T3: 87 Fill <br />4 T4: Diesel Fill <br />Bucket Installation Type: x Direct Bury <br />1-'; Contained in Sump <br />x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury <br />❑ Contained in Sump <br />xDirect Bury <br />❑ Contained in Sum <br />Bucket Diameter: 1.2" <br />12" <br />1259 <br />12" <br />Bucket Depth: 12" <br />12'/4" <br />12'/4" <br />161/4" <br />Wait time between applying 1 minute <br />vacuum/water and start of test: <br />I minute <br />I minute <br />1 minute <br />Test Start Time (Tj): 09:00 a.m. <br />09:00 am. <br />09:00 a.m. <br />09:45 a.m. <br />Initial Reading (Ri): 10 518" <br />113/16" <br />115/8" <br />14 5/8" <br />Test End Time (TF): 10:12 a.m. <br />10:12 a.m. <br />10:12 a.m. <br />10:45 a.m. <br />Final Reading (RF): 105/8" <br />113/16" <br />115/8" <br />14 5/8" <br />Test Duration (TF — Tj): 1 hr 12 min. <br />I hr 12 min. <br />I hr 12 min. <br />1 hr <br />Change in Reading (RF - RO: 0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or 1/16" <br />Criteria: <br />1116" <br />1/16" <br />1/16" <br />Test Result: I x Pass ❑ Fail <br />x Pass ❑ Fail <br />x Pass ❑ Fail <br />x Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) _ <br />Diesel fill box failed test 9:00 a.m. Re laced fill a a ter asket @nd fill ca . <br />Retested Diesel fill box and test j.swd, _ <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 01-24-2011 <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 />