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SWRCS.January 2006 <br /> Spill Bucket Vesting Report Form <br /> This jorm is lntandedfor use try cwntrocror.a perfbrmrng annual testing of(ISTspill containment xtrueturer. The completed form and <br /> prrnrours from tests(if applicable),should be provided to the facility owner/nperator for submirral 10 the lo-cal regulatory 42'ems, <br /> 1. FACIL('i('Y Il\'FORMATYOIY <br /> Facility Name: Gaited Gas Date of Testing; 06/302414 <br /> Facility Address: 3440 E.Main St.,Stockton,Ca,95205 <br /> Facility Contact: Jeary Jino Lee Phone: (209)46 <br /> Date Local Agency Was Notified of Testing _ <br /> Deme of focal Agency Inspector(fpresent during testing): !ef> Wong <br /> I <br /> 2. TESTLNG CONTRACTOR INFURM_A_ION <br /> Company Name; Relud,le Petroleum ServiCeS, Inc. ENVIRONMENTAL HEA H <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials'; x CSLS Contractor x ICC DEPARTMENT <br /> Service Tech O S WRCB Tank Tester U Outer(Spec fyj <br /> License Number(s): 883706 5250451-UT <br /> 3. SPII.L BUCKET TESTING LNFORMATION <br /> Test Mrthod Used: xNydros:atic C Vacuum C Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: NIA <br /> Identify Spill Bucket(Ity Tanit ] Tl:' <br /> hl Fill 2 T2:89 Fill 3 T3: 87 fill 4 T4: <br /> Number, Stored Prnduc4 erc.) <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury Direct Bury <br /> 0 Contained in Stun 0 Contained in Sump 0 Contained in Sum m Contained in Su <br /> Bucket Diameter: _ 12" 12" <br /> 12" <br /> Bucket Depth: 131/41, 14" l4 'A' <br /> Wait time between applying <br /> vwuum/water and start of test: I minute 1 minute E minute <br /> Test StartTune(Tr): 09:04 a.m. 09:04 a.m. 09:04 a.m. <br /> Initial Reading(R.)- 12 3/8" 13 y," 13 1/2n <br /> Test Eud Time 1,1'F): 10:04 a.m, l0:04 a.m. 10:04 a.m. <br /> Final Rcading(Rp): 12 3/8" 13 '/." <br /> Test Duration(TF—T): 1111 Ihr 1 hr <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or ` <br /> Crkeri a: L 116" <br /> Teat Result: x pas- U Fail x Pass ❑Fail x Pass 0 Fall Paas II Fail <br /> Comments—(include information on repairs.rade prior to testing,and recommended follow-upforfaded tests) <br /> CERTE)KATION OF TECHNICIAN RESPONSIBLE FOR CONULCT1NG THIS TESTING <br /> Y Hereby certify&W all the information contained in thin report 4 true,accurate, and in full comptiance with legal requiremetrts. <br /> Technician's Signature: hate 06/30/2014 <br /> State !aws and regulations do not currently require testing to be performed by a qualified contractor.However, local requirements <br /> tray be more stringent. <br /> O L-d £9699b960Z wneloiled elgeile2j ebb:90 V 1 1£Int <br />