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S WRCB,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(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHANE & DAVE'S I Date of Testing: MAR 12, 2010 <br /> Facility Address: 3550 HWY 99, STOCKTON, CA 95215 <br /> Facility Contact: MIKE ELIASON I Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: MAR 1, 2010 <br /> Name of Local Agency Inspector(ifpresent during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials': ® CSLB Contractor ® 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: ® Hydrostatic ❑ Vacuum ❑ Other(Specify) <br /> Test Equipment Used: VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 87 FILL RED DIESEL FILL <br /> Bucket Installation Type: ® Direct Bury ®Direct Bury ❑ Direct Bury ❑ 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: 13.00" 12.50" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:00 AM 9:00 AM <br /> Initial Reading(Ri): 11.50" 11.00" <br /> Test End Time(TF): 10:00 AM 10:00 AM <br /> Final Reading(RF): 11.50" 11.00" <br /> Test Duration(TF—TO: 1 HR 1 HR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed 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 /> i <br /> Technician's Signature: v lam` G ``' Date: MAR 12,2010 <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 />