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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 completed form and <br /> printouts from tests(if applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHANE B RAVES Date of Testing: 3/23/2011 <br /> Facility Address: 3550 HWY 99, STOCKTON, CA 95215 <br /> Facility Contact: MIKE ELIASON Phone: (209) 948-9412 <br /> Date Local Agency Was Notified of Testing: 2/15/2011 <br /> Name of Local Agency Inspector(i(present during testing): J. WONG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials: E CSLB Contractor E ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 803705(CSLB Contractor)—1048103-UT(ICC Service Tech.)—'90-1200(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other(Specify) <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 87 PILL RED DIESEL FILL <br /> Bucket Installation Type: E Direct Bury E Direct Bury ❑ Direct Bury El Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11.50" 11.50" <br /> Bucket Depth: 12.50" 13" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(T1): 9:00 AM 9:00 AM <br /> Initial Reading(Ri): 11" 11.50" <br /> Test End Time(TF): 10:00 AM 10:00 AM <br /> Final Reading(RF): 11" 11.50" <br /> Test Duration(TF—Tt): 1 HR 1 HR <br /> Change in Reading(RF-Rj): 0" 0" <br /> Pass/Fail Threshold or Criteria: 1/16" 1/16" <br /> Test Result: ® Pass ❑Fail E Pass [] Fail ❑ Pass [:] Fail ❑'Pass ❑Fail' <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for jailed tests) <br /> CERTIFICATION OF TECHNICIAN 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: Date: 3/23/2011 <br /> 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 />