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MAR-12-2012 14:11 Service Station Systems 408 938 8888 P.02 <br /> Spill Bucket Testing Report Form SWRCB,January 2006 <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 regulatoryagency, <br /> 1. FACILITY INFORMATION <br /> Facility Name; Gag-4-Less Date of Testing;2/13/12 <br /> Facility Address: 3408 Manthey Road Stockton, CA 95206- <br /> Fablity Contact: Gilbert Silva 209) 234-7869 <br /> Date Local Agency Was Notified of Testing; 2/1/12 <br /> Name of Local Agency Inspector (if present during testing); <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Bryan Lundien <br /> Credentialsi: ® CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester [] Other(Specify) <br /> License Number(s): License:485184 ICC:8001468-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 (ByTank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number, Stored Product, etc.) 01 Re u 02 Prem <br /> © <br /> Bucket Installation Type: Direct Bury ❑ Direct Bury ❑ Direct Bury E] Direct Bury <br /> ® Contained in Sump Contained in Sump ❑ Contained in Sump © Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. <br /> Bucket Depth: 13.00 in. 12.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. <br /> Test Start Time(T, ): 11.30am 11:30am <br /> Initial Reading(R, >; 12.000 in. 11,000 in. <br /> Test End Time(TF ) 12:30pm 12:30pm <br /> Final Reading(F�): 12.000 in. 11.000 in. <br /> Test Duration(TF-T,); 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: kLl Pass [] Fail [K 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 cortlfy that all the information contained In this report is true,accurate,and In full compliance with legal requirements, <br /> Technician's Signature: Date: 2/13/12 <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 />