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0 <br /> 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 owner/operator for 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. SWRCB Tank 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 Equipment Resolution:TAP <br /> Identify Spill Bucket(By Tank 1 87 FILL 2 91 FILL 3 DIESEL FILL 4 <br /> Number,Stared Product, e <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 Sump <br /> Bucket Diameter: 1211 1211 1211 <br /> Bucket Depth: 1451 14' 1419 <br /> Wait time between applying 30-MIN 30-MTN 30-MIN <br /> vacuum/water ands of test: <br /> Test Start Time(Tj): 9:OOAM 9:00AM 9:00AM <br /> Initial Reading(Rj): 14" 1411 15" <br /> Test End Time(TF): 10:OOAM 10:OOAM 10:00AM <br /> Final Reading(RF): 14" 1411 15" <br /> Test Duration(TF—Ti): l-HR 1- 1-HR <br /> Change in Reading(RF-Rj): NONE NONE NONE <br /> Pass/Fail Threshold or PASS PASS PASS <br /> Criteria: <br /> Test Result: 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 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: 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 />