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SWRCB,January 2006 <br /> L� <br /> PINNACLE 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 printouts from <br /> tests(if applicable),should be pro vided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: West Valley Auto Service Chevron Date of Testing: 6-28-2017 <br /> Facility Address: 36979 Fremont Blvd Fremont <br /> Facility contact: Site Manager Phone: 209- <br /> Name of Local Agency Inspector(ifpresent during testing} <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Pinnacle Fuel Compliance Services, Inc. <br /> Technician Conducting Test: Aneil Chand <br /> Credentials': CSLB Contractor Z ICC Service Tech. 0 SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): ICC#5119959-UT SWRCB#90-1262 CSLB#894932 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum E10ther <br /> Test Equipment Used: Tape Measure,Stop Watch Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number,Stored Product,etc.2 Super Regular Diesel <br /> Bucket Installation Type: Sump Sump Sump <br /> Direct Bu /Sum <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying 5mins 5mins 5mins <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11" 11" 11" <br /> Initial Reading(RI): 60mins 60mins 60mins <br /> Test End Time(TF): 11" 11" 11" <br /> Final Reading(RF): Omins Omins Omins <br /> Test Duration(TF-TI): 60mins 60mins 60mins <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0"-60mins 0"-60mins 0"-60mins <br /> Test Result: Pass/Fail PASS PASS PASS <br /> Comments-(Include informatton on repairs made prior to testing,and recommended I011ow--up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this repW is true,accurate,and fn full compliance with legal requirements. <br /> Technicians Signature. Date. 6/28/2017 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more <br /> stringent. <br />