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SWRCB,January 2006 <br /> Spill Bucket Testing 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility CRUISERS BP29 Date of Testing: 9/7/17 <br /> Facility Address: 1137 W LATHROP,MANTECA <br /> Facility Contact: MONICA Phone: 209-824-2760 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LC SERVICES <br /> Technician Conducting Test: PETER HUKE <br /> Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> _ X Contained in Sump X Contained in Sump X Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13" 13" 13" <br /> Wait time between applying 30 MIN 30 MIN 30 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 AM 9:00 AM 9:00 AM <br /> Initial Reading(R,): 10" 10" 10" <br /> Test End Time(TF): 10:00 AM 10:00 AM 10:00 AM <br /> Final Reading(RF): 10" FAIL 10" <br /> Test Duration(TF–Ti): 1 HR 1 HR l HR <br /> Change in Reading(RF-Rj): 0 FAIL 0 <br /> Pass/Fail Threshold or PASS FAIL PASS <br /> Criteria: <br /> Test Result: X Pass Fail Pass X Fail X Pass Fail Pass Fail <br /> Comments — (include information on repairs imide prior to testing, and recommended l)llotir-up for failed tests) <br /> .-,Y eifsei <br /> .dV i1 <br /> 9 <br /> 01 2018 <br /> )!1f EN I AL <br /> CERTIFICATION OF TECHNICIAN RESPONSI-BLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informa#o contai din this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:-9/7/17– <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 />