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Spill Bucket Testing Report Form <br /> Aisforni 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: United Parcel Service I Date of Testing: 6-14-2011 <br /> Facility Address: 1532 North Broadway-Stockton,CA 95205-T <br /> Facility Contact: Kasi Montgomring ery-Plant Engineeng Phone: (916)7084616 <br /> Date Local AgenL3 Was Notified of Testing: 5-30-2011 <br /> Name of Local Agency Inspector(if present during testing): Jeff Wong-San Joaquin County E.H.D. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: PET RO-TECHZ Environmental Services <br /> Technician Conducting Test: Dan Zeman <br /> Credentials': 0 CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): ICC Service Technician No.:5243781-UT-CAS Tank Tester License No.: 1535 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other: <br /> Test Equipment Used: Tape Measure-Lake Test Equipment Resolution: 1/16- <br /> Iden tiSpill Bucket(By Tank 1 Diesel <br /> Number, Stored Product, etc.) <br /> [Bucket Installation Type: Direct Bury <br /> Bucket Diameter: 11" <br /> Bucket Depth: 13" <br /> Wait time between appl3ing 15 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tr): 8:40 am <br /> Initial Reading(R): 123/4" <br /> Test End Time(T,): 9:40 am <br /> Final Reading(RF): 12 3/4" <br /> Test Duration(rF-T): 60 Minutes <br /> Change in Reading(RF-Rj): 0.00 <br /> Pass/Fail Threshold or 1/4""in a 24 Hr.Period <br /> Criteria: <br /> Test Result- Pass <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 cerfify that aff the information contained in this report is true,accurate,and in full co fiance with legal requirements. <br /> Technician's Signature- Date:June 14 2011 <br /> Page 5 of 5 <br />