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• She 45 � t*. res <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <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 ('(applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: <br />Emies General Store I Date of Testing: 1/27/2017 <br />Facility Address: <br />4407 E Waterloo Rd Stockton Ca <br />Facility Contact: <br />Ernest G 209-931-2850 <br />1 Diesel <br />2 <br />3 <br />4 <br />2 TFSTlrNA CONTRACTOR INFORMATION <br />Company Name: ELITE IV CONTRACTORS <br />Technician Conducting Test: Mike Kennard <br />Credentials: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Spec) <br />LicenseNumber(s): ICC5254811 / OPWI04790 <br />a curr Ti UITri[FT TF.RTIN[: INFORMATION <br />Test Method Used: X Hydrostatic Vacuum Other <br />Test Equipment Used: N/A I <br />Equipment Resolution: <br />I <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 Diesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />11 1/2 <br />Bucket Depth: <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />5Min <br />Test Start Time (Tj): <br />11:30 <br />Initial Reading (Ri): <br />1115/16 <br />Test End Time (TF): <br />12:30 <br />Final Reading (RF): <br />1115/16 <br />Test Duration (TF — TO: <br />60 min <br />Change in Reading (RF - RD: <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Pass <br />Test Result: <br />I X Pass ❑ Fail <br />❑ Pass ❑ Fail <br />D Pass ❑ Fail <br />❑Pass ❑Fail <br />Comments — (include informalion on repairs made prior to testing, and recommended follow-up forfailed tests) <br />Replaced swivel adaptor on diesel tested bucket with 5 gallon ok <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: 1/27/2017 <br />i <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 />