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• • SWRCB,January 2006 <br /> Spill Bucket Testing Report Form , n - 13 <br /> This form is intended for use by contractors performing annual testing of.UST spill containment structures. The com gletedform and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regul tory agency. <br /> 1.. FACMI TY INFORMATION <br /> Facility Name: KWIK SERV I Date of Testing: 10-17-13 <br /> Facility Address:824 E YOSEMITE AVE MANTECA,CA <br /> Facility Contact Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): INSP ON SITE / NO INSP ON 3ITE <br /> 2. TESTING CONTRACTOR INFORMATION . <br /> Company Name: Service Station Testing,Inc. <br /> Technician Conducting Test: . Charles Ferrucci <br /> Credentials'.: ❑CSLB Contractor ❑ICC Service Tech. ' ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 5323096-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Water,Tape Measure,Stop Watch Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 PLUS VAPOR 2 PREM VAPOR 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter. 12 12 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1140 1140 <br /> Initial Reading(R): 13.25 13 <br /> Test End Time(Tr): 1240 1240 <br /> Final Reading(RF): 13.25 13 <br /> Test Duration(Tr–Tr): 1 hr 1 hr <br /> Change in Reading(RF-RD: 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria <br /> .Test Result: ® Pass 0 Fail ® Pass' ❑Fail. ❑-Pass d Fail " ❑ Pass p Fail <br /> Comments– (include information on repairs made prior to testing, and recommended ollow-u or <br /> nr <br /> IFES 12 2014 <br /> cA1111Ann AlAACAJ L <br /> HEALTH DFPAMMEN7 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the in n c d in this report is true,accurate,and in Jitll compUance with legal requirements. <br /> Technician's Signature: ��/�— Date: <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 />