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SWKCB,January 2006 <br /> Spill Bucket T estillg 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: VILLAGE WEST MARINA Date of Testing: 03-16-2017 <br /> Facility Address: 6649 EMBARCADERO DRIVE,STOCKTON,CA 95219 <br /> Facility Contact: TIM FONTAINE Phone: (209)97-Vl= `. <br /> Date Local Agency Was Notified of Testing: 03-7-2017 : J 1H <br /> Name of Local Agency Inspector(f present during testir.97): VICKI MCC"RTNEY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: KAISER COMMERCIAL PETROLEUM r=NNjiRnNMENTAL HE <br /> Technician Conducting Test: GREG KAISER IDEPARTMENT <br /> Credentials': ®CSLB Contractor ®ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): CSLB No. 859535,ICC No.5252318 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic 7 Vacuum ❑Other <br /> Test Equipment Used: H2O,TAPE MEASURE. Equipment Resolution: 1l32 <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, ere.) PREMIUM 1 DIESEL 2 <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury 0 Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 16 13'/2 <br /> Wait time between applying <br /> vacuutn/water and start of test: <br /> Test Start Time(T,): 9:10 9:14 <br /> Initial Reading(Ri): 131/2 12 <br /> u <br /> Test End Time(TF): 10:10 10:14 <br /> Final Reading(RF): 14" 12" <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 0 <br /> Pas ail Threshold or <br /> Criteria: PASS PASS <br /> Test Result: N Pass ❑ Fail ® Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-u for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TFSTING <br /> I hereby certify that all die information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> v <br /> Technician's Signature: Date: 03-16-2017 <br /> ' State laws and regulations do not cui, ntly require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />