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VIT <br /> 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:West Valley Auto Service Date of Testing:03/05/2018 <br /> Facility Address:2615 West Grant Road,Tracy,CA 91342 <br /> Facility Contact:Rick Branchini Phone:925-699-1396 <br /> Date Local Agency Was Notified of Testing:2/12/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Confidence UST Services <br /> Technician Conducting Test:Kyle Self <br /> Credentials`: V CSLB Contractor V ICC Service Tech. J SWRCB Tank Tester Other(Spec) <br /> License Number(s):804904 8485829 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: V Hydrostatic ❑Vacuum Other <br /> Test Equipment Used:HYDROSTATIC Equipment Resolution:0.00" <br /> Identify Spill Bucket(By Tank 187 Fill 2 91-Fill 3 Diesel Fill 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sump l7 Contained in Sump J Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12.00" 12.00" 12.00" <br /> Bucket Depth: 14.00" 14.00" 14.00" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min 5 min 5 min <br /> Test Start Time(Ti): 10:00am 10:00am 10:00am <br /> Initial Reading(RI): 11.875" 11.25" 10.75' <br /> Test End Time(TF): 11:00am 11:00am 11:00am <br /> Final Reading(RF): 11.8752 11.25" 10.75" <br /> Test Duration(TF—TI): 1 hour 1 hour 1 hour <br /> Change in Reading(RF-Rr): 0.00" 0.00" 0.00" <br /> Pass/Fail Threshold or 0.0625" 0.0625" 0.0625" <br /> Criteria: <br /> Test Result: 0 Pass ❑Fail 0 Pass ❑Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 /> Technician's Signature: Y1. Date:03/05/2018 <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 />