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L <br /> SWRCB,January 2006 <br /> Spill Bucket TeSting Report Form <br /> This form is intendedfor 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 owneloperatorfor submittal to the local regulatory agency. <br /> 1. FACMnY INFOTION <br /> Facility Name: 14&M KWIK SERV Date of Testing:RMA1-12 <br /> Facility Address: 2501 E.JACKSON <br /> Facility Contact: HASSAN Phone; (209)839-3971 <br /> Date Local Agency Was Notified of Testing: 7-17-12 <br /> L-Name ol Local Agency Inspector(ifpresent during testing): MUNIAPANAIDU <br /> 2. TIESTING CONTRACTOR]NpORMATION <br /> Company Name:LC SERVICES <br /> Technician Conducting Test:JOSE OCHOA <br /> Credentials': 0 CSLB Contractor X ICC Service Tech, 0 SWRC13 Tank Tester 0 Other(Specify) <br /> License Number(s): <br /> Test Method Used: 3. SPILL BUCKET TESTING INFORMATION <br /> X Hydrostatic 11 Vacuum 0 Other <br /> Test Equipment Used; <br /> Equipment Resolution: <br /> WIN <br /> Identify Spill Bucket(4 Tank 1 87 2 91 3 DIESEL 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: x Direct Bury X Direct Bury X Direct Bury 0 Direct Bucy <br /> 0 Contained in Sum 0 Contained in Sump 0 Contained in S2R!2 0 Contained in Sump <br /> Bucket Diameter. 1211 121, 12" <br /> Bucket Depth: -14- 20" <br /> -Wait ime between applying <br /> vacuum/water and start of test: 15 MINUTES 15 MINUTES 15 MINUTES <br /> Test Start Time(Tj): 9:00 AM 9.00 AM 9:00 AM <br /> Initial Reading(P-1), 13" 137) 191, <br /> Test End Time(TF): 10,00 AM 10:00 AM -10-00 AM <br /> Final Reading(RF): 13 13" <br /> 19" <br /> Test Duration(TF-TI): I 14i I HR I HR <br /> Change in Reading(RF Rj). 0 0 0 <br /> Pass/Fail'Threshold or <br /> Criteria: 0 0 0 <br /> a:;P-0 <br /> '0 Fall.::, <br /> XPA 7, <br /> Comme repairs m ad--prior to testing and recommended allow-upLorailed tests <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I kereby certify that all the Information contained in this report is true,aecarate,and in full compliance wfth legal reqairementL <br /> Technician's Signature: Date: 1-12 <br /> State laws and regulrations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />