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2-20-07;11:24AM;SACRAMENT0 EMC <br />;916 92S 2816 # 2/ 3 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST Will containment structures. The completed form and printouts from tests (if applicable), should be <br />provided to the facility owner/operator for submittal to the local mplatm agency. <br />1. Facility Information <br />Customer <br />Job Location <br />Work Order <br />124679 <br />7/11 # 19976 <br />1399 North Main Street <br />Manteca, Ca. 956336 <br />209-239-3252 <br />7/11 #19976 <br />1399 North Main Street <br />Manteca, Ca. 956336 <br />209-239-3252 <br />Contact <br />site No. <br />Jay Stemley <br />19976 <br />Date Local Agency was notified of testing: <br />Name of Local Agency Inspector (if present during testing) <br />2. Testing Contractor Information <br />Company Name: <br />Sacramento Equipment Maintenance Company, Inc <br />Technician Conducting Test: <br />Jim Hutchins <br />Credentials(1): <br />CSLB Contractor <br />1CC Service Tech <br />SWRCS Tank tester <br />Other (specify): <br />License Ntnnber(s): <br />502377 <br />5280194 -UT <br />3. Spill Bucket Testing Information <br />Test Method Used: <br />Hydrostatic <br />Vacuum <br />Other <br />Teat Equipment Used: <br />Water/Measure Tape <br />Equipment Resolution: <br />Identify Spill Bucket (by Tank Number, Stored <br />Product, etc.) <br />1 -T5 (91) <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />OPW <br />Bucket Diameter. <br />11 " <br />Bucket Depth: <br />12° <br />Wait time between applying vacuum/water and start <br />of test: <br />.50 hour <br />•rest Start Time (TI) <br />11:00 <br />Initial Reading (RI) <br />3 1/4 from top of cap <br />Teat End Time (If) <br />12:00 <br />Final Reading UW <br />31/4 <br />Teat Duration (Tf - Tl): <br />one hour <br />Change in Reading (Rf - RI) <br />Pass/Fail Threshold or Critera: <br />Test Ranks <br />Pass <br />Fail <br />Pass <br />Fail <br />Pass <br />Fail <br />Pass <br />Fail <br />Comments: (includes 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 />I <br />Date: <br />2-02-07 <br />(t) Mare taws ana regulations (to not currenny-tequ re testing to be pertomted by a qualitied contractor. However, local requirements may be more <br />stringent. g/c/0000f/state/spillbucket.wpd <br />