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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This fibrin is inlended.lbr use by contractors-performing annual testing of UST spill containment structures. The completed'fin-in and <br /> printoutsfromtests(#*applicable,), should be provided to the facility ownerloperalorfior submittal to the local regulatory��gellcl?. <br /> 1. FACILITY INFORMATION <br /> Facility Name: H&M KWIK SERVE BW98 Date of Testing: 9/1/2017 <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(ifpreseni during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: PETER WESTBROOK <br /> Credentials': CSLDContractoi- XICC Sci-vice'H-C.111. a VVRC B Tank Tester u Other(Specify) <br /> License Number(s):8772623 <br /> 3. SPILL BUCKET TEST INFORMATION <br /> Test Method Used: X--Hydrostatic U;Vacuum 'D Other <br /> Test Equipment Used:WATER Equipment Resolution: TAP <br /> Identify Spill Bucket (ky Tank I DSL FILL 2 91 FILL 3 4 <br /> Number, Stored Product, etc.) <br /> X Direct Bury X Direct Bury Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 14" 14" --A! <br /> Wait time between applying <br /> 30-MIN 30-MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:OOAM 9:OOAM <br /> Initial Reading(Rj): 14" 14" <br /> Test End Time(TF): 10:OOAM 10:00AM <br /> Final Reading(R,:): 2" 14" <br /> Test Duration(Ti--—Ti): I-HR 1-HR <br /> Change in Reading(Rj-P.1): N 0,4E ,.0I.&:, <br /> Pass/Fail Threshold or FAILED PASS <br /> Criteria: <br /> Test Result: Pass X Fail X Pass Fail Pass Fail 0 Pass 0 Fail <br /> Comments—(include information failed tests) <br /> REPAIRED 91 AND DSL DRAIN VALVE RETESTED 91 PASSED AND DSL_ <br /> FAILED POSSIBLE LEAK IN BUCKET ITSELF <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is trite,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 7 <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 />