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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This,/brm is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts fi-ont tests(if <br /> applicable).should be provided to the facility ownen'operator jor submittal to the local regulatory agencv. <br /> I. FACILITY INFORMATION <br /> Facility Name: lAreo 2093 jDate of Testing: 12/21/2010 <br /> Facility Address: Street: 3425 Tracy Blvd. CITY:Tracy California <br /> Facilitv Contact: 11kabob Phone: 209-485-1605 <br /> Date Local Agency Was Notified of Testing: 12-7-110 <br /> Name of Local Agency Inspector(if resent during testis ): Thu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com anv Name: Wayne Perry <br /> Technician ConductineTest: Brandon Smith <br /> Credentials: El CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br /> License Number(s): 300345 ❑ Other(Specify) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Ylethod Used: [� Hydrostatic ❑ Vacuum ❑ Other(Specrfv) <br /> Test Equipment Used: Visual Tape Equipment Resolution: <br /> 87#I87#2 870 91 <br /> Identity Spill Bucket(By Tank <br /> Number.Stored Product,etc. ❑ Fill 2 Vapor ❑ Fill 2 Vapor E] Fill Q Vapor E] Fill E] Vapor <br /> Ll Direct Bury ❑ Direct Bury ❑ Direct Bury Direct Bury <br /> Bucket Installation Type: Contained in Sum Contained in Sum Contained in Sum Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 12" 12" 12" 12" <br /> Wait time between applying <br /> vacuum/water and start of test: 15 Minutes 15 Minutes 15 Minutes 15 Minutes <br /> Test Start Time(Ti): 11:30 AM 11:30 AM 11:30 AM 11:30 AM <br /> Initial Reading(Rt):Inches 9.00 9.00 9.50 9.5 <br /> Test End Time(TF): 12:30 PM 12:30 PM 12:30 PM 12:30 PM <br /> Final Reading(RF): Inches 9.00 9.00 9.50 9'5 <br /> Test Duration(TF—Ti): 1 Hour 1 Hour 1 Hour 1 Hour <br /> Change in Reading(RF-R,): <br /> 0 0 0 0 <br /> Pass/Fail Threshold or Criteria 0 0 0 0 <br /> TeStResUlt.' ❑ ;Pass ❑ F�tl.. [] Pass:: ❑..;Fail ❑ P ss ❑ :Fast ❑ Pnae ❑ Farl <br /> Comments—(include information on repair made prior to testing, and r•ecoaunertcled follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that till the information contained in this report is trite,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 12/21/2010 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.Flowever,local requirements may be more stringent. <br />