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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 comp et <br /> En <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regul Gy <br /> EIVEL <br /> 1.FACILITY INFORMATION <br /> Facility Name:MARCH LANE SHELL Date of Testing:5/6/2015 10 All JL ix L2 8H ra <br /> Facility Address: 1206 E.MARCH LANE,STOCKTON,CA 95210 <br /> Facility Contact:KARAM SINGH Phone:510-926-7834 �, <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Gilbert Garcia <br /> Credentials): r CSLB Contractor F7 ICC Service Tech. rs SWRCB Tank Tester r` Other(Specify) <br /> License Number(s):743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic 17 Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank 1 Spill Box#Tank 2 <br /> Identify Spill Bucket(By Tank Spill Box#Tank 3 Diesel- <br /> Number, Stored Product, etc.) REGULAR-Fill 1 -Direct- PREMIUM-Fill 1-Direct- Fill 1 -Direct-Grade level Spill Box# <br /> Grade level Grade level <br /> t: Direct Bury Is Direct Bury C' Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump r Contained in Sump C Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 13.00 13.00 13.00 <br /> Wait time between applying <br /> 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:05:00 09:10:00 09:14:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:06:00 09:11:00 09:15:00 <br /> Final Reading(RF): 30.00 in.H2O 29.00 in.H2O 28.00 in.H2O <br /> Test Duration(TF—Tl): 1 min 1 min 1 min <br /> Change in Reading(RF—Rl): 0.00 in.H2O -1.00 in.H2O -2.00 in.H2O <br /> Pass/Fail"threshold or Criteria: +,/-4.00 +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIINICIAN 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: �3� - Date: 5/6/2015 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2323225 <br />