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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 8 DAVE'S I Date of Testing: 3/21/2012 <br /> Facility Address: 3550 HWY 99, STOCKTON, CA 95215 <br /> Facility Contact: Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: 3/5/2012 <br /> Name of Local Agency Inspector(ifpresent during testing): STACY RIVERA <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 /> 'fest Method Used: ® Hydrostatic ❑ Vacuum ❑ Other(Spec) <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 87 FILL RED DIESEL FILL <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury El Direct Bury E]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: 12.00" 12.00" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 8:30 AM 8:30 AM <br /> Initial Reading(Ri): r9:30 <br /> 0" 10.50" <br /> Test End Time(TF): AM 9:30 AM <br /> Final Reading(RF): 0" 10.50" <br /> Test Duration(TF—Tj): R 1 HR <br /> Change in Reading(RF-Rj): 0"Pass/Fail Threshold or Criteria: " 1/16" <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 /> Technician's Signature: Date: 3/21/2012 <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 />