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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 I Date of Testing: 1-20-10 <br /> Facility Address: 1001 E.YOSEMITE,MANTECA,CA 95336 <br /> Facility Contact: BILLA I Phone: 209-825-4569 <br /> Date Local Agency Was Notified of Testing: 12-31-09 <br /> Name of Local Agency Inspector(f present during testing): MUNI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-SERVICE STATION TESTING <br /> Technician Conducting Test: HEATH MCEVER <br /> Credentials': ❑CSLB Contractor ❑ICC Service Tech. X SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 04-1677 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:WATER Equipment Resolution:INCHES <br /> Identify Spill Bucket(By Tank 187 291 3 DSL 4 <br /> Number,.Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Symp ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12.25 14 14.5 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 0902 0902 0902 <br /> Initial Reading(RI): 11.25 13 13 <br /> Test End Time(TF): 1002 1002 1002 <br /> Final Reading(RF): 11,25 13 13 <br /> Test Duration(TF—T): 1 HR 1 HR 1 HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Resait: IFail ❑ Pass ❑Fail ❑ Pass Q Fail 0 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 Informado tained in this report is true,accurate,and In full compliance with legal requirements <br /> Technician's Signature: Date: It <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 />