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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. <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the to lgenc <br /> 1. FACILITY INFORMATION F <br /> Facility Name: Unocal Date of Testing:12/15/16 }AN, 13 2017 <br /> Facility Address: 2701 West March Lane Stockton, CA 95219 <br /> Facility contact: Darren Eppler (209)473-7337 TT <br /> Date Local Agency Was Notified of Testing: 11/11/16 <br /> Name of Local Agency Inspector (if present during testing): Vicki McCartney -' <br /> Mff <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialsi: I]CSLB Contractor ©ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 lcc:5258560-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used; ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number,Stored Product,etc.) 01 -Re u 02-Prem 03-Diesel <br /> Bucket Installation Type: ®Direct Bury ® Direct Bury IA Direct Bury ❑ Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. 14.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. 5 min. <br /> Test start Time IT,): 10:20am 10:20am 10:20am <br /> Initial Reading(R,): 14.000 in. 14.000 in. 14.000 in. <br /> Test End Time(TF): 11:20am 11:20am 11:20am <br /> Final Reading(F�-): 14.000 in. 14.000 in. 14.000 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0:0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fall Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: IM Pass ❑ Fail Pass ❑Fail ®Pass ❑Fail []Pass ❑,Fag <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 /> !hereby certify thatall the Info ation contained In this report Is true,accurate,and in full compliance with legal requirements. <br /> Technician's Date <br /> Signature: +"� — • 12/15/16 <br /> 9 <br /> 1 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 />