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iN3niHVd30 <br /> H-LIVDH WiN3VYN0d1AN3 <br /> 11H 5 1 AON <br /> SWRCB,January 2006 <br /> gid.. . <br /> 101JAP <br /> Spill Bucket Testing Report Form <br /> isform Ism en a ntractors 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: Valero Date of Testing: 11/8/2017 <br /> Facility Address: 1210 E.Hammer LN. <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Nucleus Pump Services <br /> Technician Conducting Test: <br /> Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB'Tank Tester 0 Other(Specify) <br /> License Number(s): ICC# <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used:Water H2O Measure Tape Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1- 2- 3 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: Direct Bury Direct Bury ❑Direct Bury ❑Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11" <br /> Bucket Depth: 12" <br /> Wait time between applying 5 Min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:10 <br /> Initial Reading(Rj): 12.5 <br /> Test End Time(TF): 11:10 <br /> Final Reading(RF): 12.5 <br /> Test Duration(TF—Tj): 1 Hour <br /> Change in Reading(RF-Rj): 0.00 <br /> Pass/Fail Threshold or Drop In Water Ht. Drop In Water Ht. <br /> Criteria: <br /> Test Result: x Pass n Fail Pass a Fail Pass Fail 13 Pass 13 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 a information contained in this report is true,accurate,and in full compliance with legal requirement& <br /> ' State Iaws an regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />