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71 <br /> iSWRCB,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: 412/2013 <br /> Facility Address: 3550 HWY 99,SIOCKTON, CA 95215 <br /> Facility Contact: MIKE ELIASON Phone: <br /> Date Local Agency Was Notified of Testing: 3/27113 <br /> Name of Local Agency Inspector(fpresent during testing): STACEY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials: ®CSLB Contractor ❑ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 803705(CSLB Contractor)—5254736-UT(ICC Service Tech.)—06-1672(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other(Spec) <br /> Test Equipment Used: VISUAL- TAPE MEASURE Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 87 FILL RED DIESEL FILL <br /> ®Direct Bury ® Direct Bury ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 12" 12" <br /> Wait time between applying 10 MIN 10 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:00 AM 9:00 AM <br /> Initial Reading(RI): 1.5"FROM TOP 1.5"FROM TOP <br /> Test End Time(TF): 10:00 AM 10:00 AM <br /> Final Reading(RF): 1.5"FROM TOP 1.5" FROM TOP <br /> Test Duration(TF-Tj): 1 HR 1 HR <br /> Change in Reading(RF-Rj): 10 0 <br /> Pass/Fail Threshold or Criteria: NO LOSS NO LOSS ENOLOSSNO LOSS <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ED] 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 /> Technician's Signature: t----a, ut---5 Date: 412/2013 <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 />