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I Y 11-e SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to thefacility owner/operator for submittal to the local regulatory agency. 1- FACILITY INFORMATION Facility Name: PERSHING BEACON Date of Testing: 1-29-2015 Facility Address: 4445 N PERSHING STOCKTON CA Equipment Resolution: 1 / 16 Identify Spill Bucket (By Tank Number, Stored Product, etc. Facility Contact: I Phone: 2 91 3 DSL 4 WASTE OIL Date Local Agency Was Notified of Testing :1-16-15 Name of Local Agency Inspector (if present during testing): FATIMA MAR 19 2015 2. TESTING CONTRACTOR INFORMATION tNVIKUNU Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Faj206YWI Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: h20 and tape measure Equipment Resolution: 1 / 16 Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 91 3 DSL 4 WASTE OIL Bucket Installation Type: ® Direct Bury ❑ Contained in Sump ® Direct Bury F1Contained in Sump ® Direct Bury Contained in Sum ® Direct Bury ❑ Contained in Sum Bucket Diameter: 11 11 11 11 Bucket Depth: 14.25 13.75 14 11.25 Wait time between applying vacuum/water and start of test: Test Start Time (T,): 9 9 9 9 Initial Reading (R,): 13 13 13 11 Test End Time (TF): 10 10 10 10 Final Reading (RF): 13 13 13 11 Test Duration (TF — Tt): 1 HR IHR IHR I H R Change in Reading (RF -R,): 0 1 0 1 0 1 0 Pass/Fail Threshold or Criteria: 1/16 1/16 1/16 1/16 Test Result: ® Pass ❑ Fail ®Pass ❑ Fail I ® Pass ❑ Fail ® Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) OPW ALL PASSED CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date 1-29-2015 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.