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0 ec(R� <br /> CCO1 +fEK.CCM-UMCE <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(f 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: 11/30/2017 <br /> Facility Address: 15 E.Grant Line Rd.,Tracy,CA 95376 <br /> Facility Contact: Varinder Pal Singh Phone: (209)481-4099 <br /> Date Local Agency Was Notified of Testing: 11/09/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): John Alaniz <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(Spec) <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 1 Super 2 Regular Syphon 3 Regular 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury El Direct Bury ❑Direct Bury [I Direct Bury <br /> ®Contained in Sump Z Contained in Sump Z Contained in Sump ❑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): 09:55 AM 09:55 AM 09:55 AM <br /> Initial Reading(RI): 11 1/2 Inches 12 Inches 11 Inches <br /> Fest End Time(TF): 10:55 AM 10:55 AM 10:55 AM <br /> Final Reading(RF): 11 1/2 Inches 12 Inches 9 Inches <br /> Test Duration(TF—TI): 60 Minutes 60 Minutes 60 Minutes <br /> Change in Reading(RF-RI): 0 Inches 0 Inches 2 Inches <br /> Pass/Fail Threshold or 1/16 Inches 1/16 Inches 1/16 Inches <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail Z Pass ❑ Fail 1 ❑ Pass Z ,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 failed the test and must be replaced and retested. <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: ZroV Date: 11/30/2017 <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 />