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SWRCB,January 2006 <br /> Spill 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: Valero Date of Testing: 1-28-11 <br /> Facility Address: 1001 Main St Manteca 95336 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: l jW- <br /> Technician Conducting Test: Jt� t 1 <br /> Credentials': U CSLB Contractor BICC Service Tech. U SWRCB Tank Tester U Other S ci <br /> License Number(s): 3 ( <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: drostatic U Vacuum U Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 8-1 2 4t t 3 D C e4( 4 <br /> Number.Stored oduct etc. <br /> Bucket Installation Type: WDirect Bury PDirect Bury 4-Ifirect Bury U Direct Bury <br /> o ta' edin S o tained' um o o d in Sumn <br /> Bucket Diameter: 11'l, <br /> Bucket Depth: 13 yi l 3 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T Cl C4 us- <br /> Initial Reading(RI): 2 fM i,( 1.3 4a <br /> Test End Time(TF): 1():15 /D•' S /D /S <br /> Final Reading(RF): 11-SA4 3/14 1 1/ <br /> Test Duration F-TI): 1A) r 1.0 Ar 1.° h✓ <br /> Change in Reading(RF-R;): D D U <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Mass ❑Fail Bass ❑Fail ass ❑Fail ❑ Pass ❑Fail <br /> Comments-(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compUance with legal requirement& <br /> Technician's Signature: U�4JL\ Date: 1-28-11 <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 />