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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: Shell/Tesoro Date of Testing:5/30/12 <br /> Facility Address: 2448 W. Kettleman Ln. Lodi, CA 95242 <br /> Facility Contact: Mary Morgan (209)369-3124 <br /> Date Local Agency Was Notified of Testing: 5/22/12 <br /> [Name of Local Agency Inspector (if present during testing): Aris Cacapit <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test; Ryan Casey <br /> Credentials: ❑X CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8057554-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> IdentifySpill Bucket cket (By7ank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number, Stored Product,etc.) 01 Regu 02 Prem 03 Diesel <br /> E] Direct Bury ❑ Direct Bury E] Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> ® Contained in Sump ❑X Contained in Sump ❑X Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 12.00 in. 12.00 in. 16.00 in. <br /> Wait time between applying 15 min. 15 min. 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti ): 9:15am 9:15am 9:15am <br /> Initial Reading(R, ): 11.500 in. 11.750 in. 13.500 in. <br /> Test End Time(TF): 10:15am 10:15am 10:15am <br /> Final Reading(RF): 11.500 in. 11.750 in. 13.500 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: Q Pass ❑ Fail ❑X Pass ❑ Fail 0 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: ��` Date: 5/30/12 <br /> 1 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 />