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ill <br />11 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spilt containment structures. The completed farm, and <br />printouts from tests (if applicable), should be provided to the facility owner/operato o m' a l agency. <br />T, FACILITY INFORMATION <br />Facility Name: ESCALON MINI MART Date of Testing: 1/27/2416 <br />Facility Address: 1097 E. YOSEMITE <br />Facility Contact: BILL Phone: 249) 838-1546 <br />Date Local Agency Was Notified of Testing: -- L HEALTH <br />Name of Local Agency Inspector i resent durin testing): CINDY VO -7,7,777R -,, M -EN1 g y � (fp g �� <br />TESTING CONTRACTOR INFORMATION <br />Company Name: FRANZEN-HILL <br />Technician Conducting Test: JOSE OCHOA <br />Credentials': ❑ CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester 0 Other (Spec) <br />License Number(s): <br />SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />X Hydrostatic U Vacuum <br />9 87 <br />X Direct Bury X Direct Bury <br />Contained in Sump Contained in Sump <br />u vu►oa <br />Resolution <br />ham- FaFt�. <br />Direct Bury Direct Bury <br />Contained in Sump Contained in Sump <br />Test Equipment UsedEquipment <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />Bucket Diameter: <br />12" <br />12" <br />14" <br />14" <br />BucketDepth: <br />15 MINUTES <br />1:05 PM <br />15 MINUTES <br />1:05 PM <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />14" <br />14" <br />Initial Reading (RI): <br />2:05 PM <br />2:05 PM <br />Test End Time (TF): <br />Final Reading (RF): <br />14" <br />IHR <br />0 <br />0 <br />X Pass Fail <br />14" <br />I HR <br />Test Duration (TF - TI): <br />0 <br />Change in Reading (RF - RI): <br />0 <br />X Pass Fail <br />Pass Fail <br />Pass Fail <br />T <br />Pass/Fail Threshold or <br />Criteria: <br />Test ReWt. <br />Comments -- (include information on repairs made prior to testing, and <br />recommended follow-up, for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUC'T'ING THIS TESTING <br />I hereby certify that all the ' o anon contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 1/27/2016 <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 />