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Spill Bucket Testing Report Form 0 <br /> Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed,oras and <br /> printoutsfrom tests(if applicable),should be provided to the facilityowner/opemtorforsubmittal to the local regulatory agency. <br /> FACILITY INFORMATION Facility ID: 01 <br /> Facility Name: Shell Oil Products Date of Testing:9/29/2014 <br /> Facility Address: 3515 Navy Dc,Stockton,CA 95203 <br /> Facility Contact: Miguel Tones Phone: <br /> Date Local Agency Was Notified of Testing 2014-09-19 _ <br /> Name of Local Agency Inspector(fpresent during testing): Michelle Henry U <br /> TESTING CONTRACTOR INFORMATION OCT <br /> 2 ma <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test. Victor Guerrero '�( ' � ALTH <br /> Credentials • 14 CSLB Contractor ICCServiceTech C` SWRCBTankTester F Other(Specify) <br /> License number(s):A B ASB C-10 HAZ License Number 588098 : 8017001-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test M ethod U sed: FHydrostatic I—Vacuum r— other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank I Slop Tank <br /> Num ber,Stored Product,etc. <br /> Bucket Installation Type: r Direct Bury r Direct Bury I—Direct Bury (— Direct Bury <br /> F Contained in Sump r Contained in Sump r Contained in Sump r— Contained in Sump <br /> r On top of AST r On top of AST r On top of AST r On top of AST <br /> Bucket Diameter: 11" <br /> Bucket Depth: 11" <br /> Wait time between applying 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:30 am <br /> Initial Reading(RI): 9.75" <br /> Test End Time(TF): 10:30 am <br /> Final Reading(RF): 9.75" <br /> Test Duration(TF—TI): I hour <br /> Change in Reading(RF-R]): 0 <br /> PassiFailThreshold or 0 <br /> Criteria: <br /> Test Result r Pass r Fail r Pass 1— Fail r Pass r Fail r Pass r Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Test water put into slop tank. <br /> CERTIFICATION OFTECHNICIAN 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: 66jrA. _..� Date: 9/29/2014 <br />