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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 contpleted form and <br />printouts front 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: Kaiser Manteca Date of Testing: 7/8/2016 <br />Facility Address: 1777 W. Yosemite Avenue <br />Facility Contact: Phone: m <br />Date Local Agency Was Notified of Testing: 6/15/2016 <br />Name of Local Agency Inspector (if present during testing): <br />"oftto lt! <br />2. TESTING CONTRACTOR INFORMATION L,; L6L <br />Company Name: Belshire Environmental Services, Inc. <br />Technician Conducting Test: David Walker <br />Credentials': W CSLB Contractor ❑ICC Service Tech. ❑ SWRCB Tank Tester ❑Other (Specify) <br />License Number(s): 808,313 <br />3. SPHA, BUCKET TESTING INFORMATION <br />Test Method Used: OH drostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Visual Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Diesel UST <br />2 3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />Bucket Diameter: <br />14" <br />Bucket Depth: <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 Minutes <br />Test Start Time (Tj): <br />09:17 AM <br />Initial Reading (Rr): <br />1.5" From Top <br />Test End Time (TF): <br />10:17 AM <br />Final Reading (RF): <br />1.5' From Top <br />Test Duration (TF — TI): <br />1 Hour <br />Change in Reading (RF -RT): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />No visable loss <br />Test Result: <br />5s ❑Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />❑Pass ❑Fail <br />Comments — (include infonnation on repairs made prior to testing, and reconumertded 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 compliance with legal requirements. <br />Technician's Signature:. !� -a: _ �1 Date: 7/8/2016 <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 />