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RECEIVEL, <br />Spill Bucket Testing Report Form SWRC13jJaprga2f08015 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The compt�}t WNMENTAI <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulat n <br />IT. <br />1. FACILITY INFORMATION <br />Facility Name: Shell/Tesoro Date of Testing: 05/28/15 <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 1 esting: 5/20/15 <br />LName of local Agency Inspector (rf present during testing) Michelle Henry <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: Myke Briggs <br />Credentialst: Z CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:8033115-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑X Hydrostatic Y ❑ Vacuurn ❑ Other <br />Test Equipment Used: Measuring Tape Equipment Resolution.1 /16 In. <br />(dent fy Spill Bucket (By Tanu <br />Number, Stored Product, etc) <br />1 Fill Bucket <br />01- Renu <br />2 Fill Bucket <br />02 - Prem <br />3 Fill Bucket <br />03 - Diesel <br />4 <br />Bucket Installation Type: <br />L]Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />❑x Contained in Sump <br />L]Direct Bury <br />Contained in Sump <br />❑ Direct Bury ~ <br />❑ 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 />11.00 in. <br />Wait time between applying <br />vaarumiwater and start of test: <br />1 min. <br />1 min. <br />1 min. <br />Test Start 1 ime (T, ): <br />10:00am <br />10:00am <br />10:00am <br />Initial Reading (R t <br />10.75 in. <br />10.50 in. <br />10.25 in. <br />Test End Time (1F ): <br />11:00am <br />11:00am <br />11:00am <br />Final Reading (f; ): <br />10.75 in. <br />10.50 in. <br />10.25 in, <br />Test Duration (TF - T i): <br />1.00 hr. <br />1 00 hr. <br />1.00 hr. <br />Change in Reading (RF - R; ): <br />0.000 In. <br />0.000 In. <br />0.000 in. <br />PassiFail Threshold or Criteria. <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />❑x Pass ❑ Fail <br />[ Pass ❑ Fad <br />❑X Pass ❑ Fail <br />❑ 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 />l - <br />%���'`��_ . <br />Technician's Signature: Date 05/28/15 <br />t State laws and regulations do riot currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />