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SWRC:B,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of USTspill containment structures. The completedform and <br /> printouts from tests(if applicable),should be provided to the facility ownerioperalor for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 76 Express I Date of Testing: 5/2812010 <br /> Facility Address: 419 S Main Manteca 95366 <br /> Facility Contact: Bobby Phone: (209)239-7978 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if resent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ft F1Q1 lF-R SL N C-U <br /> Technician Conducting Test: CPO-L- >-�q.�^'!, Eni d Eru G N <br /> Credentials': SLS Contractor ACC Service Tech. i SWRCB Tank Tester 'Other(S eci ) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: !Hydrostatic 1.Vacuum l:Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 ( 2 3 4 <br /> Number.Stored Product etc. U1 L- <br /> Bucket Installation Type: erect Bury XDirect Bury Abirect Bury !Direct Bury <br /> i-Contained in Sump Contaiped in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: v <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and start of test: /cS <br /> Test Start Time(T 1): 17 A R <br /> Initial Reading(Rj): �'' 40 <br /> Test End Time(TF): rte: i,- <br /> Final Reading(RF): 0 CZ a <br /> Test Duration(TF-Tj): / h 2 1l>P- ioz <br /> Change in Reading(RF-R1): d <0-3 <br /> Pass/Fail Threshold or <br /> Criteria <br /> Test Result: ❑ Pass l-Fail ,-Pass ❑Fail XPaSs ❑Fail ❑ Pass 0 Fail <br /> Comments- include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> bp-t;iv r-A"'Efl - 1*)2AIN PaES Nd% S�hL C�Nt�IFr f/L}y <br /> AA:R + .Se l- J £c—i c1ti <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 /> �~ 5/28/2010Technician's Signature:�A-P t--• 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 />