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0 99 E CZ1, � an la, D <br />Spill Bucket Testing Report Form 9 6 2017 <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 f applicable), should be provided to the facility ownerloperator for submittal toPe loc 1 re latory agn y,,,_ <br />1 Ti ArTt Yrt V YWWn0A4Ar"nN — -- — •. s-, tea: I – r. <br />Facility Name: ESCALON MINI MART Date of Testing: 1-11-16 <br />Facility Address: 1097 E. YOSEMITE <br />Facility Contact: BILL Phone: (209) 838-1546 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (fpresent during testing): <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 ❑ Other <br />License Number(s): <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />5,�.:,:�.,.rs1.?u1•.:3.`:�n. ,v.:.`,�_,...a�<,_'�i ... ,. <..;.; <br />Identify Spill Bucket (By Tank <br />Number, Stored Product; etc:) <br />..u.....,.�. :'.. �..�.T.. ,, �.,.>_. ;. <br />87 <br />'` . ,.. �..._:. .... s..::;_r,.. .. -:.:' .+..�.'. <br />91 <br />...,.0. t��,. ,,..,. ; _Lay.?._ _.�, <br />r �i, Y= ., .-�._� ,. ,..., _....., z�<.. <br />Bucket Installation Type: <br />X Direct Bury <br />Contained in Sump <br />X Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 MINUTES <br />15 MINUTES <br />Test Start Time (Ti): <br />9:00 AM <br />9:00 AM <br />Initial Reading (Ri): <br />14" <br />14" <br />Test End Time (TF): <br />10:00 AM <br />10:00 AM <br />Final Reading (RF): <br />6" <br />14" <br />Test Duration (TF — TI): <br />1HR <br />1 HR <br />Change in Reading (RF - Ri): <br />9" <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />Pass XYail <br />Pass X Fail <br />Pass' Fail <br />Pass Fail <br />Comments — (include information on repairs made prior to testing, and <br />recommended follow-up for failed tests) <br />87 SPILL BUCKET FAILED LEAK TEST AND DRAIN TEST. <br />91 SPILL BUCKET PASSED LEAK TEST BUT FABLED DRAIN TEST. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the it4ormation contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 1-11-16 <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 />