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ece� <br /> 6Ct1=E>A6N 60MPliPNC[ <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: Tracy Market I Date of Testing: 01/29/2018 <br /> Facility Address: 15 E.Grant Line Rd.,Tracy,CA 95376 <br /> Facility Contact: Varinder Pal Singh I Phone: (209)481-4099 <br /> Date Local Agency Was Notified of Testing: 01/25/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nik Zagorov <br /> Credentials': Z CSLB Contractor Z ICC Service Tech. Z SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 958763 A <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank I Regular 2 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑ Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Z Contained in Sum ❑ Contained in Sum ❑Contained in Sum ❑ Contained in Sum <br /> Bucket Diameter: 12 Inches <br /> Bucket Depth: 12 Inches <br /> Wait time between applying 10 MinuteszF l ' <br /> vacuum/water and start of test: P F( <br /> Test Start Time(Tj): 02:30 PM <br /> Initial Reading(Rj): 12 1/8 Inches <br /> Jr iN r`" <br /> 0 2018 <br /> Test End Time(TF): 03:30 PM <br /> Final Reading(RF): 12 1/8 Inches 1-A TW <br /> Test Duration(TF-Ti): 60 Minutes Qr.,r <br /> Change in Reading(RF-Rj): 0 Inches m <br /> Pass/Fail Threshold or 1/16 Inches <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 /> Tank Regular Spill Bucket was replaced "like for like"and retested with passing result. <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: roV Date:01/29/2018 <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 />