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Spifl Bucket Testing Report Form <br /> This form is intended for use by contractors perfornung annual testing of USTspill containment structures The completed form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: United Parcel Service I Date of Testing: 6-15-2010 <br /> Facility-Address: 1532 North Broadway-Stockton,CA 95205 <br /> Facility-Contact: Herman Meyer-Plant Engineering I Phone: (916)373-4001 <br /> Date Local Agency Was Notified of Testing: 5-25-2010 <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: PETRO-TECHZ Environmental Services <br /> Technician Conducting Test: Dan Zeman <br /> Credentials': ❑CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): ICC Service Technician No.:5243781-UT-CA SW RCB 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 /> Identify-Spill Bucket(By Tank 1 Unleaded <br /> :Number, Stored Product, etc.) <br /> Bucket Installation T)-pe: Direct Bury <br /> Bucket Diameter: 11"" <br /> Bucket Depth: 13" <br /> Wait time between applying 1-Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 8:48 am <br /> Initial Reading(RI): 123/;' <br /> Test End Time(TF): 9:48 am <br /> Final Reading(RF): 123/4" <br /> Test Duration(TF-TO: 60 Minutes <br /> Change in Reading(RF-RI): 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 certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: c> r,Z Date:June 15,2010 <br /> Page 5 of 5 <br />