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o <br /> SVVRCB,January 2006 <br /> Spill Bucket-Testing Report Form <br /> This form is intended for use by contractors performing <br /> annual facility <br /> of'JSTsp"'containment structures.The complet <br /> printouts from tests(if applicable),should be provided to <br /> the <br /> c 1, onerloperator for submittal to the local regula"OVEOEIVED <br /> 1. FACILITY INFORMATION <br /> Facility Name: H&M Market I Date of Testing:07/31/18 AUG 2 7 2 )1 <br /> -Facility-Address: 2501 Jackson Ave. Escalon, CA 95320- <br /> Facility Contact: Unknown (209)838-3971 ENVIRONME JTAL <br /> Date Local Agency Was Notified of Testing: 7/26/18 HEALTH IDERAF TMENT <br /> Name of Local Agency inspector (if present during testing): Aaron Hang <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Randy.Wilkerson <br /> Gredentialsi: CSLB Contractor [@ ICC Service Tech. 0 SWRCB Tank Tester El other(Specify) <br /> License License:485184 ICC:5258560-VT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum El Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:)/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> 7;e <br /> Number,Stored Product,etc.) - 01 -Req.0 02-Prem 03-Diesel <br /> Direct Bury Direct Bury Fx Direct Bury Direct Bury <br /> Bucket Installation Type: Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: <br /> Bucket Depth: 14.25 in. 14.25 in. 14.25 in. <br /> Wait time between applying 10 min. 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time IT, 12:34pm 12:36p.m 12:37pm <br /> Initial Reading(Ri 14.250 in. 14.250 in. 14.500 in. <br /> Test End Time(TF 1:35pm 1:37pm 1:40pm <br /> Final Reading(r�): 13.750 in. 14.250 in. 14.500 in. <br /> Test Duration(TF-T1): 1.02 hr. 1.02 hr. 1.05 hr, <br /> Change in Reading(RF -R, -0.500 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria- ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: Fall Q Pass Fail Pass 0 Fad 0 Pass M Fail <br /> Comments: 87 Bucket Failed due to Leaking Between Sleeve& Bucket <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the?Intforpation contained In this report is true,accurate,and In full compliance with legal requirements. <br /> Date,07/31/18 <br /> Technician's Signature; <br /> 1 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 />