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SWIZCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> T his form is intended far use hJz contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts fiY)m tests(if applicable), should be prorided to the faeilitt-owner/operatorfor submittal to the local regzdauwr ,agenc.v. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Manteca CO Date of Testing:8/3/2017 <br /> Facility Address:430 W. Center Street <br /> Facility Contact:Richard Silvera Phone:(209) 0258 a <br /> Date Local Agency Was Notified of Testing: --Oy of Local Agency Inspector(ifpresent during testing): <br /> !;.. <br /> 2. TESTING CONTRACTOR.INFORMATION <br /> Company Name:SunWest Engineering Const., Inc. <br /> Technician Conducting Test:David Smith <br /> Credentials': ❑CSLB Contractor ®ICC Service Tech. ❑SWRCB Tank Tester DOther(Speciji) <br /> License Number(s):8260473 <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method,Used: [D Hydrostatic ❑Vacuum []Other <br /> Test Equipment Used:Tape measure/visual Equipment Resolution: <br /> Identify Spill Bucket(Bv Tank 1 Tank 1 2 3 4 <br /> 'umber, Stored Product,etc.) <br /> Bucket Installation.Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury []Direct Bury <br /> ElContained in Sum []Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter(inches): 12" <br /> Bucket Depth(inches): 11" <br /> Wait thrie(nun)between applying 15 min <br /> vaeuumhvater and start of test: <br /> Test Start Time(Ti): 0830 <br /> Initial heading(Rj): 0 .25 <br /> Test End Time(TF): 0930 <br /> Final Reading(Rr): 0 .25 <br /> Test Duration(Tr—Tj): 1 hr <br /> Change in Reading(Rt:-RI): 0 <br /> Pass/Fail Threshold or .002 <br /> Criteria: <br /> Test Result: 21 Pass ❑Fail ❑Pass ❑Fail []Pass ❑Fail ❑Pass El Fail <br /> Comments—(include information on repairs made prior to testis>,and recotntnended.follovv-up fin-jailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all lite infbrtnation contained in this report is true,accurate,and in full compliance with legal requirements. <br /> David Smith ' -S-W-OPt.asy q.n by a o-<tinWcs!Engtrmenng,au=StNC. <br /> a��a��. ,� nv <z ,n4.a .a-US 8/3/2017 <br /> Technician's Signature: D t..2017O&910-9a07107W Date. <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 />