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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 forst 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 /> i <br /> Name of Local Agency Inspector(if present during <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LC SERVICES <br /> Teclmician Conducting Test: PETER HUKE I <br /> Credentialst: CSLB Contractor X TCC Service Tech. SWRCB Tank Tester Other(Specify) j <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION J <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: I <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number,Stored Produce, etc) i <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(Rt): 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): l HR I HR, I HR <br /> Change in Reading(Rr-Ri): 0 FAIL 0 { <br /> Pass/Fal <br /> Threshold or PASS FAIL PASS <br /> Crit na <br /> Test Result: X Pass Fall Pass X Fall --XPass Fall Pass Fail <br /> Comments-(include Information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> l <br /> i <br /> I <br /> CERTIFICATION OFT HNICIAN RE,E,SPONS LE-FOR CONDUCTING THIS TESTI['iNG <br /> I hereby certify that all the informati ntal d in this r rt is true,accurate,and in full compliance with legal requirements. <br /> i <br /> Technician's Signature: Date: 9/7/17 <br /> i <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 /> I <br /> 1 <br /> i <br />