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• • SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisfori i is intended for use by contractors performing annual testing of USTspill containment structures. The completedform and <br /> printout from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: Systems Transport I Date of Testing: May 19,2009 <br /> Facility Address: 707 E. Roth Road,French Camp,CA 95231 <br /> Facility Contact: Steve Tucker Phone: 209.983.8654 <br /> Date Local Agency Was Notified of Testing : May 6,2009 <br /> Name of Local Agency Inspector(fpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Compan Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. <br /> Technlet Conducting Test: Mike Jones <br /> Credenti s': ❑CSLB Contractor (x)ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License umber(s): ICC 5254644-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: (x)Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) DIESEL TANK <br /> Bucket I stallation Type: x Direct Bury ❑Direct Bury El Direct Bury El Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket I iameter: 12 INCH <br /> BucketDepth: 11 INCH <br /> Wait time between applying 5 MIN. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:28 a.m. <br /> Initial Reading(R[): 11 INCH <br /> Test End Time(TF): 10:30 a.m. <br /> Final Reading(RF): 11 INCH <br /> Test Duration(TF—Ti): IH U <br /> Change in Reading(RF-Rj): -0- <br /> Pass/Fail Threshold or PASS <br /> Criteria: <br /> Test Re ult: (X) Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comm nts— (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 hereb certify that all the information contained in this report is true,accurate, and in full compliance with legal requirements. <br /> Technic an's Signature: -Mike Jones Date: May 19,2009 <br /> State lam s and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be n ore stringent. <br /> Page 4 of 4 <br />