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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: United Gas I Date of Testing: 06/30/2014 <br /> Facility Address: 3440 E.Main St.,Stockton,Ca.95205 <br /> Facility Contact: Jean/Jino Lee Phone: (209)463-7716 <br /> L <br /> Local Agency Was Notified of Testing: Orl-3)-/q <br /> of Local Agency Inspector(f present during testing): Jeff Wong <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 ❑Other(Spec) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution:N/A <br /> Identify Spill Bucket(By Tank 1 T1: 91 Fill 2 T2: 89 Fill 3 T3: 87 Fill 4 T4: <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13 '/4" 14" 14''/a" <br /> Wait time between applying 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 09:04 a.m. 09:04 a.m. 09:04 a.m. <br /> Initial Reading(Rj): 12 3/8" 13 '/4" 13 '/2" <br /> Test End Time(TF): 10:04 a.m. 10:04 a.m. 10:04 a.m. <br /> Final Reading(RF): 12 3/8" 13 '/4" 13 '/z" <br /> Test Duration(TF—Tj): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass ❑Fail x Pass ❑Fail x Pass ❑ Fail Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 Signatur Date 06/30/2014 <br /> .47 <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 />