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03/14/2016 09: 36 9163712540 BZ h4AINT PAGE 04105 <br /> Spill Bucket Testing Report Form ,1 PR 06 2016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The,completed form and <br /> printoutsfrom tests(if applicable), should be provided to the facility ownerioperator for submittal to the local regulato?y agncy. <br /> 1.FACILITY 7Nk'O1lZIVIATI0N <br /> Facility Name: COUNTRY MARKET PLACE Date of Testing:3/10/2015 <br /> Facility Address: 1789 W CHARTER WAY City: STOCKTON <br /> Facility Contact: HARP Phone: 209-941-2222 <br /> Date Local Agency Was Notified of Testing : Tuesday,February 24,2015 <br /> Name oI Local Agency inspector(tf present during testing); STAC'Y R><VI�R.'� <br /> 2.'TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: ALEXANDER TATE <br /> Credentials: CSLB Contractor ® 1GC Service Teck. SV�rRC;13 Tank Tester [3 Other(Specify} <br /> License Number(s): 433159 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used- 7[ Hydrostatic ❑Vacuum [] Other <br /> Test Equipment Used: RULER <br /> Equipment Resolution: 1116" <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> Direct Bury U Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type; <br /> ❑Contained in Sump ❑Contained in Sump El Contained in Sam Contained in Sum. <br /> Bucket Diameter; 12" 1 z" <br /> Bucket Depth: 14.25" 14.25" <br /> Wait time between applying 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 10:20 10.20 <br /> Initial Reading(Rj): 13.25" 14" <br /> Test End Time(TF): 11.20 11:20 <br /> Final Reading(TRF): 14 <br /> Test Duration(TF—Tj): 1 HR 1 HR <br /> Change in Reading(RF--R): NIA 0 <br /> Pass/1'ail Threshold or 0 0 <br /> Criteria: <br /> pp <br /> I w -l� l h ..,� �� r�Fa�S.I ❑��I_❑ <br /> Co>a nients_ include information on repairs made prior to testing, and recommended ollow-u or ailed tests) <br /> 87 SPILL BUCKET UNABLE TO COMPLETE TEST DUE TO DIRT IN THE DRAIN,NEED TO CLEAN <br /> OR REPLACE .AND RETEST <br /> 3/24/15 - REPLACED DRAIN VALVE ON 87 SPILL BUCKET <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report ig true, accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:3/10/2015 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However. local require merits may be more <br /> stringent. <br /> Monitoring Certification Test Report <br /> 4 of 4 <br />