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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: Kaiser Manteca Date of Testing: 6/27/2018 <br /> Facility Address: 1777 W.Yosemite Avenue <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 6/7/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Belshire Environmental Services,Inc. <br /> Technician Conducting Test: David Walker <br /> Credentialsr: ®CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 808313 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: WHydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Visual Equipment Resolution: ±0.0625 <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) Diesel UST <br /> Bucket Installation Type: Direct Bury . <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying <br /> 5 Minutes <br /> vacuum water and start of test: <br /> Test Start Time(Tr): 9:22 AM ENVIRONMEN <br /> Initial Reading(Rr): 11.25" AIT <br /> Test End Time(TF): 10:22 AM <br /> Final Reading(RF): 11.25" <br /> Test Duration(TF—Tr): 1 Hour <br /> Change in Reading(RF-Rr): 0 <br /> Pass/Fail Threshold or No Leaks <br /> Criteria: <br /> Test Result: WPass ❑Fail ❑Pass ❑Fail ❑Pass El Fail ❑Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing,and recoraanaended follow-aap 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:. , U jk--- Date: 6/27/2018 <br /> a 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 />