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SWRCB,January 2006 <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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: H&M KWIK SERVE BW98 Date of Testing: 10/6/2017 <br /> Facility Address: 2501 E.JACKSON <br /> Facility Contact: MODESTO Phone: 209-838-3971 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: PETER WESTBROOK <br /> Credentials': CSLB Contractor X ICC Service Tech. SWRCBT ank Tester Other(Specify) <br /> License Number(s):8772623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic Vacuum Other <br /> Test Equipment Used:WATER <br /> Equipment Resolution:TAP <br /> Identify Spill Bucket(By Tank 1 87 RLL 2 91 FILL 3 DIESEL FILL 4 <br /> Number,Stored Product, <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth. 14" 14" 14" <br /> Wait time between applying 30-MIN 30-MIN 30-MIN <br /> vacuum/water ands of test: <br /> Test Start Time(Ti): 9:OOAM 9:OOAM 9:OOAM <br /> Initial Reading(Rj): 14" 14" 15" <br /> Test End Time(TF): 10:OOAM 10:00AM I O:OOAM <br /> Final Reading(RF): 14" 14" 15" <br /> Test Duration(TF—Tj): I-HR 1-HR 1-HR <br /> Change in Reading(RF-Ri): NONE NONE NONE <br /> Pass/Fail Threshold or PASS PASS PASS <br /> Criteria: I <br /> Test Result: I X Pass Fail X Pass Fail X Pass Fail Pass Fail. <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSHILE 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: Date: lo - 4 - 17 <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 />