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RECEIVED <br /> P 0 5 2018 <br /> SWRCB, <br /> Spill Bucket Testing Report Form E I January 2006 <br /> ME N T A L <br /> HEALTH DEPARTMENT <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 ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: H &M Market Date of Testing:08/06/18 <br /> Facility Address: 2501 Jackson Ave. Escalon, CA 95320- <br /> Facility Contact: Unknown (209) 838-3971 <br /> Date Local Agency Was Notified of Testing: 8/2/18 <br /> Name of Local Agency Inspector (if present during testing): Zuna Barker <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Able Maintenance, Inc. <br /> Technician Conducting Test: Sammy Sousa <br /> Credentials): [K CSLB Contractor [@ ICC Service Tech. E]SWRCB Tank Tester [] Other(Specify) <br /> License Number(s): License:312844 ICC:5254516-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑vacuum [] Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:)/16 in. <br /> Identify Spill Bucket (By Tank I Fill Bucket 2 Vapor Bucket 13 4 <br /> Number,Stored Product,etc.) 87 Re u87 Re 87 R <br /> Bucket Installation Type: ® Direct Bury Direct Bury ❑ Direct Bury E] Direct Bury <br /> E] Contained in Sump F-1 Contained in Sump ❑ Contained in Sump n Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. <br /> Bucket Depth: 12.25 in. 12.25 in. <br /> Wait time between applying 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time(TI 9:00arn 9:00arn <br /> Initial Reading(131 12,125 in. 12.120 in. <br /> Test End Time(TF 1 0:00am 1 0:00am <br /> Final Reading(R-): 12.125 in. 12.120 in. <br /> Test Duration(TF-T j): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R, 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria'. ZERO LOSS ZERO LOSS I <br /> Test Result: Q Pass p Fail Pass ❑ Fail C]Pass ❑Fail ❑ Pass Fail <br /> Comments: Installed New FiliNapor Buckets. Replaced Vapor Riser. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the information contained in this report is true,accurateand in full compliance with legal requirements. <br /> Technician's Signature: Date: 08/06/18 <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 />