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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 <br />Date of Testing: 5/29/13 <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: 5/22/13 <br />Name of Local Agency Inspector (if present during testing)' Arls CaCapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Raamon Frazier <br />Credentialsi : ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License:485184 ICC:8020732-UT <br />3. SPILL BUCKET TESTING INFORMATION <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 Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 Regu <br />2 Fill Bucket ___[]3 <br />02 Prem <br />Fill Bucket <br />03 Diesel <br />4 <br />Bucket Installation Type: <br />E]Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />❑X Contained in Sump <br />E]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 />10.00 in. <br />10.00 in. <br />10.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />1 min. <br />1 min. <br />1 min. <br />Test Start Time (Ti ): <br />10:00am <br />10:00am <br />10:00am <br />Initial Reading (R, ): <br />11.500 in. <br />11.750 in. <br />11.000 in. <br />Test End Time (TF ): <br />11:00am <br />11:00am <br />11:00am <br />Final Reading (F� ): <br />11.500 in. <br />11.750 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 />❑X Pass [] Fail <br />❑X Pass ❑ Fail <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 />Technician's Signature: <br />Date 5/29/13 <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 />