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N <br />0 0 <br />Spill Bucket Testing Report Form PASS <br />SWRCB, January 2006 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ECONO GAS I Date of Testing: 09 - <br />Facility Address: 880 E. VICTOR ROAD, LODI <br />Facility Contact: MR. SINGH Phone: 209-369-0958 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (f present during testing): ARTS CACAPIT ENVI <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: RYAN OLIVAS <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 433159 <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: BEAKER Equipment Resolution: 0 <br />777777,177,7777 17777-7777Identify <br />Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />2 3 <br />4 <br />Bucket Installation Type: X Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: 12 <br />Bucket Depth: 14 %: <br />Wait time between applying 0 <br />vacuum/water and start of test: <br />Test Start Time (TI): 3 PM <br />Initial Reading (Rj): 14'/: <br />Test End Time (TF): 4 PM <br />Final Reading (RF): 14% <br />Test Duration (TF — TI): 1 HR <br />Change in Reading (RF—RI): 0 <br />Pass/Fail Threshold or 0 <br />Criteria: <br />Test Result: X Pass . ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass 0 Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />87 SPILL BUCKET REPLACED <br />TECHNICIAN: RYAN OLIVAS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby cert] that all the i adon contained in this report is true, accurate, and in full compliance with legal requirements <br />1 k <br />Techni an's Signature:0�—Date: 09-20-10 <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 />