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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisform is inte <br /> nded or use b contractorsperformingannual testin o UST spill containment structures. The com leted orm and <br /> .f f Y g f P P .f <br /> printouts from tests(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: RAMOS OIL IDate of Testing: 10/31/2011 <br /> Facility Address: 10842 S.HARLAN ROAD,FRENCH CAMP, CA 95231 <br /> Facility Contact: DAVE NELSON I Phone: (916)371-3289 <br /> Date Local Agency Was Notified of Testing: 1012812011 <br /> Name of Local Agency Inspector(fpresent during testing): THOY TRAM <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials': ®CSLB Contractor ®ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705(CSLB Contractor)—1048103-UT(ICC Service Tech.)—90-1200(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑Other(Spec) <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1116" <br /> 77 <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) DUESEL FILL <br /> Bucket Installation Type: ❑ Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> ®Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11.501, <br /> Bucket Depth: 14.50" <br /> Wait time between applying 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:35 AM <br /> Initial Reading(RI): 13.00" <br /> Test End Time(TF): 10:35 AM <br /> Final Reading(RF): 13.00" <br /> Test Duration(TF—Tj): 1 HR <br /> Change in Reading(RF-RI): 0" <br /> Pass/Fail Threshold or Criteria: 1116" <br /> Test Result.. Z: Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ 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 information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: �='"�s ''r `" Date: 10/31/2011 <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 />