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JAN XnQ3, January 2006 <br />Spill Bucket Testing Report Form <br />IR® NTA ort ---4 <br />This form is intended for use by contractors performing annual testing of UST spill containment r f <br />printouts from tests (if applicable), should be provided to the facility owner/operator for subink l a ory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ESCALON MINI MART Date of Testing: 1/27/2016 <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 (f present during testing): CINDY VO <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: <br />Test Equipment Used: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (RI): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF — TI): <br />Change in Reading (RF -RI): <br />Pass/Fail Threshold or <br />SPILL BUCKET TESTING INFORMATION <br />X Hydrostatic ❑ Vacuum ❑ Other <br />Equipment Resolution: <br />87 �91 <br />X Direct Bury X Direct Bury Direct Bury <br />Contained in Sump Contained in Sump Contained in Sump <br />12" 12" <br />14" 14" <br />15MINUTES <br />15 MINUTES <br />1:05 PM <br />1:05 PM <br />14" <br />14" <br />2:05 PM <br />2:05 PM <br />14" <br />14" <br />1 HR <br />i HR <br />0 <br />0 <br />0 <br />0 <br />Direct Bury <br />Contained in <br />Criteria <br />Test Result- X Pass Fail X Pass Fail Pass Fait Pam Fail <br />Comments — (include information on repairs made prior to testing, and <br />recommended follow-up for failed tests) <br />CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the ' ormation 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 />