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SWRCB,Januarx,2006 <br /> Spill Bucket Testing Report Form <br /> This jbrnt is intended for use by conn-actors performing annual testing(?I'U,5T spill containment structures. The completed.lbrin and <br /> printouts from tests(if applicable), should be provided to the facility owner1qpera1orj6r submittal to the local regulatory agenq,. <br /> I. FACILITY INFORAIIIATION <br /> Facility Name: H &M KWIK SERVE BW98 Date of Testing: 10/161/2017 <br /> Facilites 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(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES <br /> Technician Conducting Test: PETER WESTBROOK <br /> Credentials': [i CSLB Contractor X [CC Service Tech. L]SWRCB Tank Tester E Other(5peciTy) <br /> License Number(s):8772623 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X--Hydrostatic Vacuum U;Other <br /> Test Equipment Used: WATER Equipment Resolution: TAP <br /> Identify Spill Bucket (Bj,Tank I DSL FILL 2 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: X Direct Bury Direct Bury Direct Bury Direct Bury, <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter- 12" <br /> Bucket Depth: <br /> Wait time between applying 30-MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00AM <br /> Initial Reading(Rj): 14" <br /> Test End Time(TF): I O:OOAM <br /> Final Reading(RF): 14" <br /> Test Duration(TF—Tj): I-HR <br /> Change in Reading(RF-Re): NONE <br /> Pass/Fail Threshold or PASS <br /> Criteria: <br /> Test R wit: X IPass Fail X Pass Fail Pass Fail U Pass 0 Fail <br /> Comments—(include information on repairs made Lrior to testing, and i-econittiendedLfolloit,-ip.for failed les/s) <br /> i I [ E I <br /> 1 � 1; 1 LACING DSL SPILL L, 'ET ALL!EST PASSED <br /> 17 11 ! <br /> RETEST! -011 %; E�`A[!!- 1 L 1. -d- - <br /> CERTIFICATION OF TECHN!C!AN RESPONISIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify/hat all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature:����� Date: /0— 1/4;—/7 1----,-..----- <br /> State laws and,regoilations do not ctirrently require testing to be perfon-ned by a qualified contractor. However, local requirements <br /> may be more stringent. <br />