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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structursetd <br /> e . The compleform and <br /> printouts from 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:Wine Country 76 Date of Testing: 10/20/2011 <br /> Facility Address:1111 E. Kettleman Lane, Lodi CA <br /> Facility Contact: Sonny Phone:209-369-3633 <br /> Date Local Agency Was Notified of Testing: 10/04/2011 <br /> Name of Local Agency Inspector(fpresent during testing):Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test:Robert Barnhart <br /> Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s):883706 5252540-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equ <br /> — ipment Resolution: N/A <br /> — — <br /> Identity Spill Bucket (By Tank T-I 87 FILL T-2 91 FILL T-3 DIESEL <br /> Number, Stored Product, etc. BUCKET BUCKET FILL BUCKET <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury ❑Direct Bury <br /> ❑Contained in Sum ❑Contained in Sum <br /> Bucket Diameter: 12" 11 Contained in Sump 11 Contained in Sum <br /> 12" 12" <br /> Bucket Depth: 14%a" 14'/," 141/411 <br /> Wait time between applying <br /> vacuum/water and start of test: 1 MIN 1 MIN I MIN <br /> Test Start Time(T,): 9:06AM 9:07AM 9:07AM <br /> Initial Reading(Ri): 13" 12" 12" <br /> Test End Time(TF): 10:06AM 10:07AM 10:07AM <br /> Final Reading(RF): 13" " <br /> 12 12" <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" 1/16" 1/16" <br /> Test Result: X Pass ❑Fail X Pass ❑Fail Xr Pass ❑Fail ❑ Pass D Fail <br /> Comments— (include information on re airs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby eentily that all the information contained in this report is true,accurate, and in full compliance with legal requirements. <br /> Technician's Signature: <br /> Date:10/20/2011 <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 />