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RECEIVED <br /> Spill Bucket Testing Report Form IVyf�f,faquanJ806 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. T.he co �1 to (p <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to thff t HEALTH <br /> 1. FACILITY INFORMATION DEPARTMENT <br /> Facility Name: Gas 4 Less Date of Testing: 12/13/17 <br /> Facility Address: 3434 Manthey Road Stockton, CA 95206- <br /> Facility Contact: Jesus Jurado (209)234-7869 <br /> Date Local Agency Was Noted of Testing: 11/27/17 <br /> Name of Local Agency Inspector (if present during testing): Cesar Ruvalcaba <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Kris Bell <br /> Credentialsi: ❑X 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 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number, Stored Product etc.) 01 - Re u 02 - Prem <br /> Bucket Installation Type: E] Direct Bury E] Direct Bury E] Direct Bury E] Direct Bury <br /> ❑x Contained in Sump © Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 13.00 in. 12.75 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 10 min. 10 min. <br /> Test Start Time(T,): 10:25am 10:28am <br /> Initial Reading(RI ): 12.875 in. 11.500 in, <br /> Test End Time(TF): 11:25am 11:28am <br /> Final Reading(l�): 12,875 in. 11.500 in. <br /> Test Duration(TF -T i): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ 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 /> I hereby certify that all the info n cc alned in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Data: 12/13/17 <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 />