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ec(!� <br />ECO CNEk COMPLIANCE <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_ FACTIJTV INFORMATION <br />Facility Name: Bonfare #35 1 Date of Testing: 12/13/2011 <br />Facility Address: 15 E. Grantline Rd., Tracy, CA 95376 <br />Facility Contact: Sean Kapoor I Phone: (209) 833-9619 <br />Date Local Agency Was Notified of Testing : 11/22/2010 <br />Name of Local Agency Inspector (if present during testing): Jeff Wong <br />C Ik 1 9 110 IMM" 1141 t a I ► I To]: 0 Fild V_ 010 <br />Company Name: ECO-CHEK Compliance <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: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: 1/16 Inches <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 Super <br />2 Regular Syphon <br />3 Regular 4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />® Contained in Sump Contained in Sum <br />Bucket Diameter: <br />12 Inches <br />12 Inches <br />12 Inches <br />Bucket Depth: <br />12 Inches <br />12 Inches <br />12 Inches <br />Wait time between applying <br />vacuum/water and start of test: <br />10 Minutes <br />10 Minutes <br />10 Minutes <br />Test Start Time (Ti): <br />12:15 PM <br />12:15 PM <br />12:15 PM <br />Initial Reading (RI): <br />11 1/4 Inches <br />12 Inches <br />10 3/4 Inches <br />Test End Time (TF): <br />01:15 PM <br />01:15 PM <br />01:15 PM <br />Final Reading (RF): <br />11 1/4 Inches <br />12 Inches <br />10 3/4 Inches <br />Test Duration (TF — TI): <br />60 Minutes <br />60 Minutes <br />60 Minutes <br />Change in Reading (RF -RI): <br />0 Inches <br />0 Inches <br />0 Inches <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 Inches <br />1/16 Inches <br />1/16 Inches <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: r c>V Date: 12/13/2011 <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 />