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• 0 SWRCB,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 /> 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 1 Date of Testing: 10-6-10 <br /> Facility Address: 11 l l E.Kettleman Ln.,Lodi,CA 95240 <br /> Facility Contact: Sonne I Phone: (408)806-9148 <br /> Date Local Agency Was Notified of Testing: e q-22-1 o <br /> Name of Local Agency Inspector(if present during testing) Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 Tl: 87 Fill 2 T2: 91 Fill 3 T3: Diesel Fill 4 <br /> Number, Stored Produce, etc. <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury xDirect Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 131/2" <br /> Wait time between applying 1 minute 1 minute 1 min. <br /> vacuum/water and start of test: <br /> Test Start Time(T): 9:00 am. 9:01 a.m. 9:01a m. <br /> Initial Reading(Rj): 12 7/8" 123/4" 121/4" <br /> Test End Time(Tr): 10:00am. 10:01a.m_ 10:010.m. <br /> Final Reading(RF): 12 7/8" 123/4" 121/4" <br /> Test Duration(TF-TO: 1 hr Ihr I hr <br /> Change in Reading(RF-RO: 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass ❑Fail x Pass ❑Fail x Pass ❑Fail Pass ❑Fail <br /> Comments-(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 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 a!"' - ' Date 10-6-2010 <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 />