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SWRCB,January 20,06 <br /> Spill Bucket Testing Report Form <br /> T his.finwl is intended for use by contractors performing awntal testing of U.ST spill containment structures. The completed foriu <br /> printouts front tests(if a1)plieable), should be pr•ovicleel to the fiteilitt>o►vner/operator for submittal to the local regulator:v trgenc:v..- <br /> 1. FACILITY INFORMATION <br /> facility Name: 1-1 , M KWIK SERVE BW98 Date of Testing: 1016r2017 <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(lfpresent chn-hrg testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: PETER WESTBROOK <br /> Credentials': E CSLB Contractor X ICC Service Tech. D SWRCB Tank Tester D Other(Speci6) <br /> License Number(s):8772623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Eclentify <br /> hod Used: X-- Hydrostatic D Vacuum D Other <br /> ipment Used: WATER Equipment Resolution: TAP I <br /> Spill Bucket (fat' Tank 1 DSL FILL 2 3 1 <br /> Stored Prothro, etc.) <br /> BucketIa►staUation Type: X Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sum Contained in Sung 1 <br /> Bucket Diameter: 12" <br /> Bucket Depth: ld" - <br /> Wait time between applying 30-MIN <br /> vacuum water and start of test: <br /> Test Start Time(Ti): 1:I5PM <br /> Initial Reading(R►): <br /> 'fest End Time(Tr): 2:15PM <br /> Final Reading(Rr): 11" <br /> 'rest Duration(Ti--T►): I-HR <br /> Change in Reading(Rr-RO: NONE <br /> Pass/Fail Threshold or PASS <br /> Criteria: <br /> 1 est Result: X Pass Fail Pass X Fail Pass X Fail 0 Pass 6 Fail <br /> Comments—(inehrde information on repairs ntcrde prior to testing and reeommemlecl follow-up for failed tests) ` <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1/rercbr cetYifj'that all the fuforumtiotl eotttahted iu this report is trite,accurate,tout in full compliance witlt legal requirentents. <br /> Technician's Signature: Date: m--- <br /> State laws and regulat►ons do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />