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JUN 15 2016 <br />SWRCB�JtdnUa"0,06 <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 FAt_II ITV INGnRMeTInAI <br />Facility Name: Shell/Tesoro Date of Testing: 05/16/16 <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: 4/15/16 <br />Name of Local Agency Inspector (f present during testing): Aris Veloso <br />2. TFSTINC; CnNTRAr`TnR INGnRtUATInN <br />Company Name:Service Station Systems <br />Technician Conducting Test: Myke Briggs <br />Credentials 0 CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:8033115-UT <br />3. SPILL RLICKFT TFSTING INFnRMATION <br />Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:1/16 in. <br />Identify Spill Bucket (By Tana <br />Number, Stored Product, etc) <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />02 - Prem <br />3 Fill Bucket 4 <br />03 - Diesel <br />Bucket Installation Type: <br />E]Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />❑X Contained in Sump <br />ElDirect Bury ❑ Direct Bury <br />❑X Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />Bucket Depth: <br />11.00 in. <br />11.00 in. <br />12.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time (Ti ): <br />10:00am <br />10:00am <br />10:00am <br />Initial Reading (F� ): <br />10.500 in. <br />10.000 in. <br />11.000 in. <br />Test End Time (TF ): <br />1 1:00am <br />11:00am <br />11:00am <br />Final Reading (RF) <br />10.500 in. <br />10.000 in. <br />11.000 in. <br />Test Duration (TF -T,): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />Q Pass ❑ Fad <br />Pass ❑ Fail <br />[81 Pass ❑ Fail ❑ Pass ❑ Fad <br />Comments: Buckets pass, but the 87 and 91 do not hold 5 gallons <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate,and in full comp/lance with legal requirements. <br />Technician's Signature: Date: 05/16/16 <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 />