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Jul.26. 2018 8:17AM �,nlee Pump Co No -0318 P. 2 <br />11.3 6 <br />SW`RCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors perforining annual testing of UST spill containment structures. the completed form and <br />p-intouts fi•oln tests (if applicable), should be provided to the faeilio, o,vner,%perator for submittal to the local regulatory agency, <br />1, FACIM INFORMATION <br />Facility Name: Fast N Es)t Date of Testing: <br />Facility Address: <br />Facility Contact: Meha Phone: (209) 823.3460 <br />Date Local Agency Was Notified of Testing - 7/2312018 <br />Name of Local Agency Inspector (ifpresenr during restino. Zuna <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Donlee Pump Company <br />Technician Conducting Test: Mike Flores <br />Credentials': 0 CSLB Contractor S ICC Service Tech, SWRCB Tank Tester 0 Other (.Spe <br />LicenseNumber(s): C.,a,,,A„ <br />3. SPILL BUCKET TESTING -1NVORMATION <br />Test Method Used: nydrostatic J Vacuum ❑ Other <br />Test Equipment Used- <br />Equipment Resolution: <br />Mw <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc-) <br />1 <br />b t elo' <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />XDirect ]fury <br />❑ Contained in Sum <br />❑ Direct Bury <br />:1 Contained in Sum <br />❑ Direct Bury <br />0 Contained in Sum <br />0 Direct Bury <br />: Contained in Sum <br />Bucket Diameter: <br />Jl r <br />Bucket Depth: <br />{ <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Tune (Ti): <br />{ ! 3 <br />Initial Reading (Ri): <br />{ <br />Test End Time (Tr): <br />Final Reading <br />Test Duration q, — T,): <br />U Y <br />Change in Reading (RF - R,): <br />Pms/Faiiteria: l Threshold or <br />Cr <br />FTXF� <br />Test Result; <br />pass ❑ Fail <br />-::::O Pass . 13Fail <br />C7 Pms 0 Fait <br />❑ 2ss '012il' <br />Comments -- (include information on repairs made prior to testing, and reconmrended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify (bar all the information contained in this report i me, accurate, and in full compliance with legal requirements. <br />c, <br />Technician's Signature: / Date: <br />'State laws and regulatio do not currently rec�a testing to be performed by a qualified contractor. Ho never local requirements <br />may be more stringen� <br />