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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: PERSHING BEACON I Date of Testing: 1-30-17 <br />Facility Address: 4445 N PERSHING STOCKTON CA 95207 <br />Facility Contact: Daljit Singh Phone: 477-8t041 <br />Date Local Agency Was Notified of Testing :1/24/17 <br />Name of Local Agency Inspector (ifpresent during testing): VICKI MAR 2 9 2017 <br />Company Name: AF1-01211'PEST 4162 n1 Street Galt, CA 95632 (209) 744- p MEW01I6 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (ByTank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />EJ Contained in <br />Sump <br />® Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />I t <br />11 <br />Bucket Depth: <br />14.25 <br />13.75 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1 <br />I <br />1 <br />Initial Reading (RI): <br />13 <br />13 <br />13 <br />Test End Time (TF): <br />2 <br />2 <br />2 <br />Final Reading (RF): <br />13 <br />13 <br />13 <br />Test Duration (TF —Tj): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF -R,): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />CruelCriteria: <br />I/16 <br />1/16 <br />I/16 <br />Test <br />®Pass ❑Fail <br />®Pass El Fail <br />®Pass El Fail <br />❑Pass E] Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW ALL PASSED <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: 1-30-17 <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 />