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0 4REGHVF-q)CO3,/ <br /> r <br /> my�� � A4 /`o I InJ €m'1-G4E%L'CxSf-�lsiE[CE <br /> Spill Bucket Testing Report Form J TT <br /> This form is intended for use by contractors performing annual testing of UST spill contai�VROAE�rhd form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for subr#If#N 799091RCITTUMtory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Bonfare#35 1 Date of Testing: 12/08/2015 <br /> Facility Address: 15 E.Grant Line Rd.,Tracy, CA 95376 <br /> Facility Contact: Ali Amiri I Phone: (925) 331-7403 <br /> Date Local Agency Was Notified of Testing: 11/25/2015 <br /> Name of Local Agency Inspector(f present during testing): Cindy Vo <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nikola Zagorov <br /> Credentials: ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 958763 A <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank I Super 2 Regular Syphon 3 Regular 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑ Direct Bun El Direct Bury ❑ Direct Bury El Direct Bury <br /> ® Contained in Sump ® Contained in Sump ® Contained in Sum ❑ Contained in Sum <br /> Bucket Diameter: 12 Inches 12 Inches 12 Inches <br /> Bucket Depth: 12 Inches 12 Inches 12 Inches <br /> Wait time between applying 10 Minutes 10 Minutes 10 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 09:45 AM 09:45 AM 09:45 AM <br /> Initial Reading(R,): 11 3/8 Inches 12 1/2 Inches 10 3/8 Inches <br /> Test End Time(TF): 10:45 AM 10:45 AM 10:45 AM <br /> Final Reading(RF): 11 3/8 Inches 12 1/2 Inches 10 3/8 Inches <br /> Test Duration(TF—T,): 60 Minutes 60 Minutes 60 Minutes <br /> Change in Reading(RF-R,): 0 Inches 0 Inches 0 Inches <br /> Pass/Fail Threshold or 1/16 Inches 1/16 Inches 1/16 Inches <br /> Criteria: <br /> Test Result: Z Pass ❑ Fail 0 Pass ❑ Fail ® Pass ❑ Fail Pass ❑ Far <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 /> hereby certify that all the information contained in this report is true, accurate,and in full compliance with legal requirements. <br /> Technician's Signature: - V'flV Date: 12/08/2015 <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 />