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t i <br /> c <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors pe forming 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: Bonfare#35 1 Date of Testing: 12/09/2014 <br /> Facility Address: 15 E.Grant Line Rd., Tracy, CA 95376 <br /> Facility Contact: Russ McLeod Phone: (209)833-9619 <br /> Date Local Agency Was Notified of Testing: 11/25/2014 A14— ff 111"M <br /> , <br /> Name of Local Agency Inspector(f present during testing): Fatinah Zareef1_1 '; _�+4 , o,, D <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nikola Zagorov <br /> Credentials': ED CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ElOth r,! ` + t LTH <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/ Level Change Indicator Equipment Resolution: 1/16"/0.0025 <br /> Identify Spill Bucket(By Tank l Super 2 Regular Syphon 3 Regular 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑ Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> M 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(Tj): 10:26 AM 11:33 AM 10:26 AM <br /> Initial Reading(RI): 10 1/2 Inches 0 10 7/8 Inches <br /> Test End Time(TF): 11:26 AM 12:03 PM 11:26 AM <br /> Final Reading(RF): 10 1/2 Inches 0 10 7/8 Inches <br /> Test Duration(TF—T,): 60 Minutes 30 Minutes 60 Minutes <br /> Change in Reading(RF-Rj): 0 Inches 0 0 Inches <br /> Pass/Fail Threshold or 1/16 Inches 0.0025 1/16 Inches 209 <br /> Criteria: <br /> Test Result. ® 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 /> Regular Syphon Tank Spill Bucket was retested with accelerated Level Change Indicator. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I Izerebv certifv that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: rC>V Date: 12/09/2014 <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 />