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r <br /> Spill Bucket Testing Report Form <br /> This fr•m is intcnded fur•use J,,v c'uutructors performing annuai testing of L SI-sail!containment structures. The completed form and <br /> printutrrs front teas(if applicuhtr). should be provided to submittal to the local regululury agency. <br /> 1. FACILITY INY014MATIOH _ <br /> Facility.Name: COUNTRY MARKET PLACE � Date of Testing: 3/8/2016 <br /> Faeiliv, address: 1789 W CitUITF..R WAY _ T City: STOCKTON <br /> Facilit% Contact: — l /'hone: - �• •• ° <br /> Date Local Agency Notified of TLrsting <br /> Nale u1 Lur;11 :1 ��c. ln_,l ectvr f�1 present during testing): �9rAT <br /> 2. TF:S'!'LNC CONTRACTOR� <br /> INFORMATION <br /> Company Name: Bz 5ery ice Station Maintenance <br /> Technician Conductin-! T,sr. DAVIT) ROLSE <br /> Credemiuls': CSLB Contractor TCC Service Tec'li. �SVJI:C"E3"!ank Tester Other(Sped) - <br /> Liceniv Number(;): 433159 - <br /> 3.SPI:.,- .'.:1.F TESTING INFORMATION <br /> — _. — <br /> Test Method Ltsk:.l Z 1 fydrostatic Vacuum M Other <br /> Test Equipment t ,C- lct I :It Ecu) ment Resolution: 1116" <br /> /dentin Spill 187 cJl 3 <br /> .'�'umh"r S1U!'�d 1', , ! .� <br /> Bucket <br /> Direct Bury Direct 13 ir} Direc.i Bury Direct Bury <br /> C'ontained in Sum Instaltuti ..i I . . <br /> p j ❑Contained in S,,t,t ❑ Contained in Sum E]Contained in Sum <br /> Bucket Dian7tt�r: _ 13" l3" - <br /> Bucket DgX11. 15" I{„ <br /> Wait 1Lmi1 b0h+ t:.,i .. 5 MIN S MINvact:u,tl +�atrr,tn,; :... . . . <br /> est 5tctri 1 rote t t r. 9:38 9:38 <br /> Initial keadilt,it<,;: 12" 12" <br /> {est Lnd Time l t r 1 10:38 10:38 <br /> Final Reaclin 'K,): -- 12" 12" <br /> Test Duratisn(T, l,?: 1 1.114 1 HR <br /> 00 <br /> u <br /> Pass'hiI I IIre."I -- __ <br /> Criteria: 0 0 <br /> 'I'e.t Result: ® Pass ❑ Fail Pass ❑ F: it ❑ pass ❑ Fail F-1 Pass ❑Fail <br /> _ m C ui�jtt: tts— rntcltale inJorlrration un+epuir: 0101�prior 1u ttVIS turd recvnrmended ol(ott-u ur failed Tests) <br /> CE:RTIFICA 11G`N OFTECHNICIAN HNICIAN RESPONSIBLE FOR CONDUCTING "EE11S TESTING <br /> I hereby certily i.,iia:iii tilt iufor:nation contain d in this report is true.accurate, ttnd in full compliance with legal requirements. <br /> fI 06111i6d11's Siry;i;Ik,te: -, --. ._ ._..._..-__.. .._-. .____ Date: 3/8/2016 <br /> Mate tuns attcl re'ulaltijnt Llu trot currentiy require testing;to be per6ormecl b7 a quuliticd contractor, However, local requirements may be more <br /> stringent, <br /> 111onituringC'enil:Ctltitn lest Report <br /> a of a <br />