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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: CRLLC#2705447 at of Testing: JUL 19,2010 <br /> Facility Address: 1469 E.HAMMER LANE, STOCKTON, CA 95209 <br /> Facility Contact: ARMEN MKRTYTCHIAN Phone: (925)884-0800 <br /> Date Local Agency Was Notified of Testing: JUL 8, 2010 <br /> Name of Local Agency Inspector(f present during testing): GARRETT BACKUS <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 Testerp(Specify) <br /> ❑ Other(S eci <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: VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) 91 FILL 89 FILL 87 FILL DIESEL 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: 11.50" 11.50" 11.50" 11.50" <br /> Bucket Depth: 16.00" 14.50" 15.00" 15.00" <br /> Wait time between applying 0 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9:00 AM 10:00 AM 9:00 AM 9:00 AM <br /> Initial Reading(RI): 14.50" 13.00" 13.50" 13.50" <br /> Test End Time(TF): 10:00 AM 11:00 AM 10:00 AM 10:00 AM <br /> Final Reading(RF): 14.50" 13.00" 13.50" 13.50" <br /> Test Duration(TF—TI): 1 HR 1 HR 1 HR 1 HR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result. Z Pass ❑ Fail 0 Pass ❑ Fail Z Pass ❑Fail Z 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 Si nature: ''� -«-moi'" <br /> g JUL 19,2010 <br /> Date: <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 />