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RE EIVED <br /> 0a, 2 'i Z016 <br /> ec(?( <br /> Spill Bucket Testing Report Form' NMENTAL HEALTH <br /> This form is intended for use by contractors performing annual testing of UST spill�dr�tatn o AEWcompleted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for sub 1 to he local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name. Bonfare Market#35 1 Date of Testing: 12/06/2016 <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: 11/29/2016 <br /> Name of Local Agency Inspector(if present during testing): Victoria McCartney <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 /> ,x. <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 ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Z 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): 11:10 AM 11:10 AM 11:55 AM <br /> Initial Reading(RI): 11 1/4 Inches 11 1/2 Inches 11 3/8 Inches <br /> Test End Time(TF): 12:10 PM 12:10 PM 12:55 PM <br /> Final Reading(RF): 11 1/4 Inches 11 1/2 Inches 11 3/8 Inches <br /> Test Duration(TF—TI): 60 Minutes 60 Minutes 60 Minutes <br /> Change in Reading(RF-Rj: 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: ® Pass ❑ Fail ZPass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Regular Tank Spill Bucket had no 5 Gal capacity.Spill Bucket Nipple was replaced from 7"to 4"and bucket <br /> tested with 5 Gal of test water. <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: 12/06/2016 <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 />