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08/14/2012 20:38 (209)465-4988 MaryAnn Henderson Page 6119 <br /> SWRCB,January 2006 <br /> Spill.Bucket Testing e rt 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(rf applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:. QUICK SHOP VALERO Date of Testing 01!24/201.2 <br /> Facility Address: 1001 E YOSEMITE,MANTECA,CA 95336 <br /> Facility Contact: MGR I Phone: 209-8254569 <br /> Date Local Agency Was Notified of Testing: 01/11/2012 <br /> Name of Local Agency Inspector(Ypresentduring tesft): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: SERVICE STATION TESTING-SST,INC. <br /> Technician Conducting Test: CHARLES FERRUCCI <br /> Credentials': 0 CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Sped) <br /> License Number(s): 5323096-UT <br /> 3. SPILL BUCIET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Water,Tape Measure,Stop Watch Equipment Resolution:1/16" <br /> Identify Spilt Bucket(By Tank 1 2 3 4 <br /> Lumber,Stored Product etc Diesel lar Supreme <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury 0 Direct Bury <br /> Su <br /> 0 Contained in m 0 Contained in Sump 0 Contained in Swnp 0 Contained in Sum <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 14 M2 12 t/z 141/4 <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(T�: 0900 0900 0900 <br /> Initial Reading(Ri): 133/4 11 V2 131/4 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 13314 11 1/2 13 1/4 <br /> Test Duration(TF—T�: 1 HR 1 HR I HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Passifail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: X Pass 0 FaR X P X Pass OF; 0 Pose0 Fail <br /> Comments— include ri:formation on Maws made prior to Luting,and recommendedfollow-up,forj a!led tests) <br /> CERTIFICATION OF TECEMCI PONSIBLE F NDUCTMG THIS TESTING <br /> Ihereby certify that all the info n d in this report e,and in fullcompliance xutlt legal requimmnt. <br /> Technician's Signator Date: 01/24/2012 <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,focal requirements <br /> may be more stringent. <br />