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SWRCB,MAY.4§4016 <br /> Spill Bucket Testing Report Form <br /> This roan is intended/or use by contractors performing annus!testing of UST spill containment structures. The co <br /> printouts from tests(if applicebie),should be provided to the facility e, ,1,;p <br /> for submittal to the local na!luCTTRACWT <br /> 1.FACILITY INFORMATION <br /> Facility Name: Mobil/Tesoro Date of Testing:04/26/16 <br /> Facility Address: 2132 Mariposa Rd. Stockton,CA 95205 <br /> Facility Contact: Shelly Jones (209)467-3918 <br /> Date Local Agency Was Notified of Testing: 4/8/16 <br /> Name of Local Agency Inspector (Npresentduring testing).' Vicki McCartney <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Namo:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentialsi: ®CSLB Contractor ®ICC Service Tech. ❑SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ZX Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 Fill Bucket <br /> Number,Stored Product,etc.) 01 -Re u 02- Plus 03- Prem 04-Diesel <br /> Bucket Installation Type: C3Direct Bury ❑ Direct Bury [3Direct Bury ❑ Direct Bury <br /> ® Contained In Sump ® Contained in Sump ® Contained In Sump ® Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 13.00 in. 13.00 in. 13.00 in. 13.00 in. <br /> Wait time between applying 10 min. 10 min. 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time IT,): 12:13pm 12:12pm 12:12pm 12:14pm <br /> Initial Reading(R ): 10.750 in. 10.625 in. 10.875 in. 10.438 in. <br /> Test End Time(TF): 1:13pm 1:12pm 1:12pm 1:14pm <br /> Final Reading(PF): 10.750 in. 10.625 in. 10.875 in. 10.438 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,); 0.0000 In. 0.0000 In. 0.0000 In. 0.0000 In. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: x❑Pass ❑ Fad ® Pass ❑Fail ® Pees ❑Fail NJ Pass ❑ Fail <br /> Comments: Diesel fill adaptor loose adjusted spill bucket passed <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certNy that a0 the in/o co ained in th15 report/s true,accurate,and In full comp/lance with legal requirements. <br /> Technician's Signature: Date:04/26/16 <br /> t 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 />