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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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Valero 77 Date of Testing: 1-6-09 <br /> Facility Address: 1001 E.Yosemite Ave,Manteca,CA 95336 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Inspector Munny <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: C-Henderson Maint Company <br /> Technician Conducting Test: Gavin Williams <br /> Credentials': 0 CSL B Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 8016288-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Water Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1-87 2-91 3-Diesel 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury 0 Direct Bury <br /> 0 Contaked in§!!ap 0 Contained in§ump 0 Contained in S!np 0 Contained in <br /> Bucket Diameter: 1111 111, 1115 <br /> Bucket Depth: 12.5" 14" 13.5" <br /> Wait time between applying I hr I hr I hr <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 11:15a 11:15a 11:15a <br /> Initial Reading(Rj): 891 V 1011 <br /> Test End Time(T* I hr I hr I hr <br /> Final Reading(RF): 899 V 1419 <br /> Test Duration(TF—Ti): I hr I hr I hr <br /> Change in Reading(RF-Rj): No No No <br /> Pass/Fail Threshold or Pass Pass Pass <br /> Criteria: <br /> Test Result: x pass 0 Fail x pass 0 Fan X Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-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 compliance with legal require menft <br /> Technician's Signature: 4��IA� Date: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />