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S W RCB, 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 />printoutsfrom tests (if applicable), should be provided to the facilityowner/operator for submittal io the local regulatory agenc.,T H <br />1. FACILITY INFORMATION <br />Facility Name: YRC #813 <br />Date of Testing: 02/01/2018 <br />Facility Address: 1535 E. Pescadero Avenue Tracy, CA <br />Facility Contact: Ruben Phone: (913) 344-3644 <br />Date Local Agency Was Notified of Testing :1119/2018 <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Confidence UST Services, Inc. <br />Technician Conducting Test: Aaron Perrigo <br />Credentials': Z CSLB Contractor ❑x ICC Service Tech. ❑SWRCB Tank Tester []Other (Spec) <br />License Number(s): CSLB# 804904 ICC# 8485827 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />❑x Hydrostatic <br />❑Vacuum <br />❑Other <br />Test Equipment Used: Lake Test <br />Equipment Resolution: 0.0625" <br />Identify Spill Bucket (Bi) Tank <br />Aumber, Stored product, etc.) <br />1 Waste oil <br />2 Ant -Freeze <br />3 Gearoil <br />4 Motor oil <br />Bucket Installation Type: <br />Z Direct Bury <br />[]Contained in Sum <br />❑x Direct Bury <br />[]Contained in Sum <br />❑x Direct Bury <br />[]Contained in Sum <br />❑x Direct Bury <br />[]Contained in Sum <br />Bucket Diameter: <br />13.00" <br />13.00" <br />13.00" <br />13.00" <br />B ticket Depth: <br />21.50" <br />21.50" <br />21.50" <br />21.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min <br />5 min <br />5 min <br />5 min <br />Test Start Time (T,): <br />9:00 am <br />9:00 am <br />9:00 am <br />9:00 am <br />Initial Reading (Rt): <br />4.25" <br />4.25" <br />4.25" <br />4.25" <br />Test End Time (TF): <br />10:00 am <br />10:00 am <br />10:00 am <br />10.45 am <br />Final Reading (RF): <br />4.25" <br />4.25" <br />4.25' <br />4.29' <br />'fest Duration(TF — <br />1 hr <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF- RI): <br />0.00" <br />0.00" <br />0.00" <br />0.00" <br />Pass/Fail Threshold or <br />Criteria: <br />0.0625" <br />0.0625" <br />0.0629' <br />0.0625" <br />Test Result: <br />❑x Pass []Fail <br />0 Pass []Fail <br />❑X Pass []Fail <br />❑x Pass ❑Fail <br />Conn meets — (include igfiwmation on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: a*n-- Date: 02101/2018 <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 />