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SWRCB.January 2006 <br /> Spill Bucket Testing Report Form <br /> This_ brm is intendedfor use hr•contractors pegorming unnuul w,rin•g n/•L`.ST'spill containment s•tructurec. The compleled•form and <br /> printouts•_from tells(?I'applic•able),shordd be proridecl io rhe•fuc r/in to the local regu/aturY agengv. <br /> _ 1. FACILITY INFORMATION _ <br /> Facility Name: CRUISERS MANTECA 13P29 L Date of Testing: 8,'25,16 <br /> Facility Address: 1 137 W LAl HROP <br /> Facility Contact: MANILA Phone: 209-824-2760 <br /> Date Local Agency Was Notified of Testing: NA <br /> Name of Local Agency Inspector(ifpresent duringlesNng) I'l,ANA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: GABRIEL VENEGAS <br /> Credentials': I 'CSLB Contractor x ICC Service Tech. SWRCB Tank Tester 7 Other(Specify) _ <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X_I lydrostatic Vacuum Other <br /> Test Equipment Llsed:WATER I•quipment Resolution:TAP - <br /> Identity Spill Bucket tB'v Tank 1 87 2 91 3 DSL 4 <br /> r�'trnlher. .Siored Prochrc t etc'.) _ <br /> Bucket Installation Type: Direct Bury Direct Bury Direct BUr\1 Direct Bury <br /> X Contained in Sump X Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13" 13" 13" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuumiwater and start of test: <br /> r <br /> Test Start Time(Ti): 130 PM 130 PM 130 PM <br /> Initial Reading(R,): 14- 15" 14 '/4" <br /> Test End Time(TF): 230 PM 230 PM 230 PM <br /> Final Reading(R,): 14" 15" 141/4 <br /> 'lest Duration(T, -T,): 1 HR IHR l HR <br /> Change in Reading(R, -R,): NONE NONE NONE <br /> Pass/Fail Threshold or NONE NONE NONE <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail Pass ❑Fail <br /> Comments— l6r.Miled tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in thisTport is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: '1�- -' Date: ` ��- <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 />