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03-10-'11 09:42 FROM-West Star Envmt Inc. +559-277-0106 T-019 P000610006 F-807 <br /> SWRCB,January 2006 <br /> SpiH 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Super Date of Testing: 3-8-11 <br /> Facility Address: 290 N.Main St. <br /> Facility Contact: Mandeep Phone: 209-239-1475 <br /> Date]Local Agency Was Notified of Testing: 3-8-11 <br /> Name of Local Agency Inspector(if present durYng testing): Muniappa Naidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 'W'est Star Environmental <br /> Technician Conducting Test: James(tom)Wall <br /> Credentials': ❑CSLB Contractor x ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Speci ) <br /> License Number(s): 8029369 <br /> 3. SWILL BUCKET TESTING INFORMATION <br /> Test Method Used: x Hydrostatic ❑Vacuum 0 Other <br /> Test Equipment Used: tape measure Equipment Resolution: <br /> Ydentify Spill Bucket(By Tank 1-preen 2-diesel 3-87 reg.un1. 4 <br /> Number,Stored Product, etc <br /> Bucket Installation Type: x Direct Bury x Direct Bury xDirect Bury ❑Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: iS" IT, 18" <br /> Wait time between applying 5min 5min 5min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1:54pm 4:20 pm 1:54pm <br /> Initial Reading(Rj): 12 9%" 12 1/z" <br /> Test End Time(TF): 2:54 pm 5:20 pm 2:54pm <br /> Final Reading(RP): 12" 9%" 12 W' <br /> Test Duration(Tr-T�: 1 hr 1hr 1 hr <br /> Change in Reading(Rf Ri) 0" 0" 046 <br /> Pass/Fail Threshold or Oin Oin Oin <br /> Criteria: <br /> Test Results xc Pats ❑Fail x Pass ❑Fall x pass ❑Fail ❑ Pass 0 Fail1 <br /> Comments--(include information on repairs made rior to test in and recommended ollow-u for ailed tests) <br /> R._ .e a,fir diesel fill bt&ket Remove brass t Reseal <br /> CERTIFICATION OF TECHMC7A1V RES PONSfOLE FOR CONDUCTING THIS TESTING <br /> Y hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> AdjTechnician's Signature: r Date:3-8-11 <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 />