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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 front 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: Arco Harney Ln Date of Testing: 6/20/2018 <br /> Facility Address: 255 E Harney Lane City: Lodi <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: Tuesday,June 12,2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: James A Williams <br /> Credentials'-: CSLB Contractor Z ICC Service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number(s): 433159 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Y <br /> Test Method Used: ® Hydrostatic Elvacuum ❑ Other <br /> Test Equipment Used: Ruler Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 87-2 <br /> Number,Stored Product, etc.) Direct Bu <br /> Direct Bury Direct Bury Direct Bury i'Y <br /> Bucket Installation Type: ®Contained in Sum ®Contained in Sump ®Contained in Sump ® Contained in Sum <br /> l2" 12" <br /> 12" 12" <br /> Bucket Diameter: <br /> Bucket Depth: <br /> 14" <br /> 14" 14" 14" <br /> Wait time between applying 0 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:55 <br /> 11:55 11:55 12:00 <br /> 11 3/4" <br /> Initial Reading(Ri): <br /> 11 1/21' 12" 11 1/2" <br /> 12:55 12:55 1:00 12:55 <br /> Test End Time(TF): 11 3/4" <br /> Final Reading(RF): <br /> 11 1/2" 12" 11 1/2 <br /> lhr Ihr 1hr Ihr <br /> Test Duration(TF—Ti): 0 <br /> Change in Reading(RF—Ri): <br /> 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Pass Fail ® Pass E]Fail ® Pass [I Fail ® Pass Fail <br /> Test Result: ® ❑ <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TEC N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all a informatio contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signa re: Date: 6/20/2018 <br /> z State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report 5 of 5 <br />