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SWRCB, January 2006 <br />Spill Bucket Testing Report Form MAR 3 0 2016 <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 />I FACIFIXTV INFORMATION <br />Facility Name: VILLAGE WEST MARINA _ Date of Testing: 03-16-2016 <br />Facility Address: 6649 EMBARCADERO DRIVE, STOCKTON, CA 95219 <br />Facility Contact: TIM FONTAINE Phone: (209) 951-1551 <br />Date Local Agency Was Notified of Testing: 03-12-2015 <br />Name of Local Agency Inspector (if present during testing): FATINAH ZAREEF <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: KAISER COMMERCIAL PETROLEUM <br />Technician Conducting Test: GREG KAISER <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): CSLB No. 859535, ICC No. 5252318 <br />A cP11.1. RIICICF.T TFSTING INFORMATION <br />Test Method Used: n Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O, TAPE MEASURE <br />Equipment Resolution: 1/32 <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc.2 PREMIUM 1 <br />Bucket Installation Type: ® Direct Bury <br />❑ Contained in Sum <br />2 <br />DIESEL 2 <br />® Direct Bury <br />❑ Contained in Sum <br />3 <br />❑ Direct Bury <br />❑ Contained in Sump <br />4 <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: 11 <br />11 <br />Bucket Depth: 16 <br />131/2 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T,): 9:00 <br />9:00 <br />Initial Reading (Rl): 13'/2 <br />12 <br />Test End Time (TF): 10:00 <br />10:00 <br />Final Reading (RF): 14'/ <br />13" <br />Test Duration (TF — TI): 1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): 0 <br />0 <br />Pass/Fail Threshold or PASS <br />Criteria: <br />PASS <br />Test Result: m Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ 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 information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />Date: 03-16-2016 <br />' State laws and regulations don�Ot �urrently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. v <br />