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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: TRACY TRUCK STOP Date of Testing: March 13, 2007 <br />Facility Address: 3940 N. Tracy Blvd., Tracy, CA 95304 <br />Facility Contact: Debbie I Phone: 209-865-5006 <br />Date Local Agency Was Notified of Testing :March 12, 2007 <br />Name of Local Agency Inspector (ifpresent during testing): Willie Ng <br />2_ TESTING CONTRACTOR INFORMATION <br />Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. <br />Technician Conducting Test: Mike Jones <br />Credentials: ❑ CSLB Contractor N ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 5254644-U1 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />MM <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.2 <br />1 <br />Unlead T-1, Octane 87 <br />2 <br />Diesel T-3 West <br />3 4 <br />Diesel T-4, East <br />Bucket Installation Type: <br />Direct Bury <br />❑ Contained in Sump <br />W Direct Bury <br />❑ Contained in Sump <br />W Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />11" <br />11" <br />Bucket Depth: <br />12" <br />12" <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />12:30 p.m. <br />12:30 p.m. <br />12:30 p.m. <br />Initial Reading (RI): <br />11-1/2" <br />6-1/2" <br />9-3/8" <br />Test End Time (TF): <br />1:30 p.m. <br />1:30 p.m. <br />1:30 p.m. <br />Final Reading (RF): <br />11-1/2" <br />6-1/2" <br />9-3/8" <br />Test Duration (TF — TI): <br />1 Hour <br />1 Hour <br />1 Houe <br />Change in Reading (RF - RI): <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test R� asx fall r Pass ❑ Ita1 Pass , E1 Fatl ❑Vass ":iJ lFail <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: dike .Tones Date: March 13, 2007 <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 />