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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: 5/29/14 <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: 5/20/14 <br />Name of Local Agency Inspector (if present during testing): Ans Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentialst Q CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:5297793-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 />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 Fill Bucket <br />01 Re u <br />2 Fill Bucket 3 Fill Bucket <br />02 Prem 03 Diesel <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑x Contained in Sump <br />❑ Direct Bury EDDirect Bury <br />Q Contained in Sump Q Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. 13.00 in. <br />Bucket Depth: <br />12.00 in. <br />12.00 in. 14.00 in. <br />Wait time between applying <br />vacuum/water and start of test <br />I <br />5 min. <br />5 min. 5 min. <br />Test Start Time (T, ): <br />9:53am <br />9:53am 9.53am <br />Initial Reading (Ri ): <br />11.938 in. <br />11.563 in. 13.875 in. <br />Test End Time (TF <br />10:53am <br />10:53am 10:53am <br />Final Reading (Rr ): <br />11.938 in. <br />11.563 in, 13.875 in. <br />Test Duration (TF - T,): <br />1.00 hr. <br />1.00 hr. 1.00 hr. <br />Change in Reading (R, - R, ): <br />0.0000 in. <br />0.0000 in. 0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS ZERO LOSS <br />Test Result: <br />© Pass ❑ Fail <br />❑X Pass ❑ Fail ❑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 />Technician's Signature: Date: 5!29/14 <br />t 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 />