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r 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(f 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: 10/18/2012 <br /> Facility Address: 1111 E.Kettleman Ln.,Lodi,CA 95240 <br /> Facility Contact: Sonnie Phone: (408)806-9148 <br /> Date Local Agency Was Notified of Testing: I o— a <br /> Name of Local Agency Inspector(ifpresent 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 Product, 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'/P 13 'h" <br /> Wait time between applying 1 min 1 min. 1 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:12 a.m. 9:10 a.m. 9:11a.m. <br /> Initial Reading(R): 13 1/8" 13 3/8" 12 '/d' <br /> Test End Time(TF): 10:12a.m. 10:10a.m. 10:1 la.m. <br /> Final Reading(RF): 13 1/8" 13 3/8" 12'/d' <br /> Test Duration(TF—T): 1 hr lhr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: I x Pass ❑Fail I x Pass ❑Fail x Pass 0 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/ G ��w Zoer� Date 10/18/2012 <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 />