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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended,lbr use by contractors performing annual testing ql'UST spill containment structures. The completed form and <br />printout.s.from tests, (if applicable), should fie provided to thefacilitv owncrlc)perator.fi)r.vubniiiiaI to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Manteca CA FO REGEN Date of Testing: 4/19/2017 <br />Facility Address: 2551 E. Louise Ave. <br />Facility Contact: Jonathan Pakele Phonc:(916)439-60j0r7f-%r—jj, <br />Date Local Agency Was Notified of Testing: I V C D <br />Name of Local Agency Inspector (� fpresent during testing): Aaron Hang <br />M" Lt ZUI( <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: R]Hydrostatic D'Vacurturt C]Other <br />Test Equipment Used: Tape measure / Visual <br />Equipment Resolution: <br />lZn-t; y ==71'ati"k <br />Number. Stored Product, etc.) <br />I Tank 1 <br />3 <br />4 <br />Bucket Installation Type. <br />❑E]Direct Bury <br />SContained in Sump <br />FIDirect Bury <br />[]Contained in Sump <br />M Direct Bury <br />OContained in Sump <br />[]Direct Bury <br />E]Contained in Sump <br />Bucket Diameter (inches): <br />12" <br />Bucket Depth (inches): <br />12" <br />Wait time (min) between applying <br />vacuum/water and start of test: <br />15 min <br />Test Start Time (Ti): <br />09:00 <br />Initial Reading (Rt): <br />1.25 Inches below grade <br />Test End Time (TF): <br />10:00 <br />Final Reading (RF): <br />1.25 Inches below grade <br />'rest Duration (TF — Tj): <br />1 hr <br />Change in Reading (Rr. - RO: <br />0,00 <br />Pass/Fail Threshold or <br />Criteria: <br />.002 <br />Test Result: <br />[D Pass El Fail <br />CIPass [,Fail <br />CIPass [Fail <br />ElPass;[,.Fail <br />Comments — (include iLonnation on repairs made prior to testiiU, and recommended Lollow-!E,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 itith legal requirements. <br />David Smith <br />Ww �, Imm sffm <br />Technician's Signature: ow.: 20,7,04.19 102725 a°°' <br />rw Date: 4/19/2017 <br />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 />