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GR Job # 1720-4947 <br />S WRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment snuc(ures. The Completed form and <br />Printouts from tests (if applicable), should be provided to the facility owneNoperator for submittal to the local regulatory agency. <br />1 17Ar11FrV1NVn0MA1rTnV <br />Facility Name: Dart Container CorpDate <br />of Testing: 12/26/2017 <br />Facility Address: 1400 E. Victor Rd <br />Lodi 95240 <br />Facility Contact: DarV1 Lee <br />Phone: 415-902-5089 <br />Dale Local Agency Was Notified of Testing: <br />Name of Localgene pector i present during testing): <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />2_ TESTING r11NTRArTnR TVVnrrMATrnW <br />Company Name: <br />Cettler-Ryan Inc., 6805 Sierra Court, Suite C, Dublin, Ca. 94568P h,4 925-551-7555 <br />Technician Conducting Test: Alexander Tate <br />Credentials: (1) <br />CSLB Contractor ICC service Tech. SWRCB Tank Tester Other (Specify) <br />License Number: <br />220793 ICC Tech Number: <br />3. SPILL RI CKFT T6RTINC INRnRMATrnN <br />Test Method Used: <br />Hydrostatic Vacuum <br />Other <br />Test Equipment Used: <br />Standard Nape Measurer <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 2 <br />3 4 <br />Bucket Installation Type- <br />uect Bury irect Bury <br />ontained in Sump 111ontained in Sump <br />irect Bury irec[ Bury <br />contained in Sump aonmined in Sump <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (Ri): <br />Test End Time (10: <br />Final Reading (Rt) <br />(Tf - Ti): <br />Reading (Rf-Ri): <br />LTesldmml,ion <br />hreshold or Criteria: <br />0 00lts: <br />Pass ail Pass ail <br />Pass ail Pass a6 <br />CERTFiCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TERTING <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: <br />Date: 1/26/2017 <br />(1) 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 />