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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 LIST 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:05/22/18 <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: 5/4/18 <br /> Name of Local Agency Inspector (if present during testing): Arron H <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Brian McPheely <br /> Credentials: ❑x CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8822062 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:)/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number, Stored Product,etc.) 01 -Re u 02- Prem 03-Diesel <br /> ❑ <br /> Bucket Installation Type: Direct Bury E] Direct Bury ❑ Direct Bury E] Direct Bury <br /> ®Contained in Sump ❑X Contained in Sump Q Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. 14.00 in. <br /> Wait time between applying 5 min. 5 min. 5 min. <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 9:30am 9:30am 9:30am <br /> Initial Reading(RI ): 13.875 in. 13.875 in. 13.625 in. <br /> Test End Time(TF): 10:30am 10:30am 10:30am <br /> Final Reading(F�): 13.875 in. 13.875 in. 13.625 in. <br /> Test Duration(TF-T1): 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: ❑X Pass ❑ Fail ❑X Pass ❑ Fail [K 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 /> /hereby certify that all n - C3the Information contained/n this report is true,accurate,and/n full compliance with legal requirements. <br /> 1�&. <br /> Technician's Signature: Date- 05/22/18 <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 />