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0 0 <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <br />nivform is intended for use by contractors performing annual testing of UST spall 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: Unified Grocers Date of Testing: 12-1-10 <br />Facility Address: 1990 Piccoli Rd. Stockton, Ca. <br />Facility Contact:— Fleet Manager -I Phone: 209-931-1990 <br />Date Local Agency Was Notified of Testing I 1-15-10 <br />Name of Local Agency Inspector (if present during testing): <br />Company Name: A & J Environmental <br />Technician Conducting Test: Asa Cosby <br />Credentials': X CSLB Contractor X ICC Service Tech. 11 SVVRCB Tank Tester L1 Other (Species) <br />License Number(s):653381 525-2300 <br />Test Method Used: X Hydrostatic 11 Vacuum El Other <br />Test Equipment Used: <br />=Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />ldiesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />X Direct Bury <br />IJ Contained in Sump <br />11 Direct Bury <br />0 Contained in Sump <br />0 Direct Bury <br />0 Contained in Sump <br />11 Direct Bury <br />11 Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />30 min. <br />Test Start Time (Ti): <br />0845/0906 <br />Initial Reading (RI): <br />4.934 / 4.936 <br />Test End Time (TF): <br />0900/0922 <br />Final Reading (RF): <br />4.936 / 4.935 <br />Test Duration (TF — Tl): <br />I hour <br />Change in Reading (RF - RI): <br />.001/.001 <br />Pass/Fail Threshold or <br />Criteria: <br />.002 <br />Test Result: <br />X Pass []Fail <br />11 Pass 0 Fail <br />11 Pass El Fail <br />[I Pass ❑Fail <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 info tion contained in1his report is true, accurate, and in full compliance with legal requirements. <br />Technician's <br />Date: J2 -J- /0 <br />State laws and regulations do not currently require testing to be p0 rmed by a qualified contractor. However, local requirements <br />may be more stringent. 1 <br />