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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 regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gas 4 Less Date of Testing: 12/29/16 <br /> Facility Address: 3434 Manthey Road Stockton, CA 95206- <br /> Facility Contact: Jesus Jurado (209)234-7869 <br /> Date Local Agency Was Notified of Testing: 12/27/16 <br /> Name of Local Agency Inspector (ifpresent during testing): Garrett Backus '" r <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems JAN 2 7711 <br /> Technician Conducting Test: Brian MCPheely <br /> Credentials: ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) WEALTH <br /> License Number(s): License:485184 ICC:8394903-UT rl,4 V IFt%,j1 <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 FIII Bucket 3 4 <br /> Number, Stored Product, etc.) 01 - Re u 02-Prem <br /> Bucket Installation Type: E] Direct Bury E] Direct Bury F] Direct Bury ElDirect Bury <br /> ❑X 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 IT,): 12:39pm 11:50am <br /> Initial Reading(R, ): 12.625 in. 11.375 in. <br /> Test End Time(TF): 1:39pm 12:50pm <br /> Final Reading(FBF); 12.625 in. 11.375 in. <br /> Test Duration(TF-Ti): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,j: 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: © Pass ❑Fail ❑X Pass ❑Fail ❑ Pass ❑Fail []Pass ❑ Fail <br /> Comments: Repaired 87 spill bucket replaced drain,drain gasket and swivel <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 /> T77� <br /> Technician's Signature: Date: 12/29/16 <br /> 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 />