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JUL-04-2011 09:50 Service Station Systems 408 938 8888 P.02 <br /> s <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form/s intended for use by contractors performing annual testing of U$T spill 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 rmgulatW agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Shall 136187 Date of Testing:6/10/11 <br /> Facility Address: 2375 W. Grant Line Tracy,CA 95376 <br /> Facility Contact; Javier (209)836-8908 <br /> Date Local Agency Was Notified of Testing; 6/7/11 <br /> Name of Local Agency Inspector (tYpresent during testing). <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test Bryan Lundien <br /> Credentialsi. ®CSLB Contractor [X@ 10C Service Tech. Q SWRCB Tank Tester Q Other(Specify) <br /> License Number(s): License:485184 ICC-8001468-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic Q vacuum Q Other <br /> Test E=quipment Used. Measuring Tape Equipment Resolution:1/16 in. <br /> rdentify Spill Bucket (ay Yank 1 Fill Bucket 2 Fill Bucket 3 Fill ucket 4 Fill Bucket <br /> rumber,Stored Product.etc.) 01 Re u 02 Plus 03 Prem 04 Diesel <br /> Direct Bury ❑Direct Bury Q Direct Bury Q Direct Bury <br /> Bucket Installation Type: <br /> ®Contained in Sump �j Contained in Sump ®Contained in Sump ®Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 12.50 in. 12.13 in. 12.25 in. 12.00 in. <br /> Wait time between applying <br /> vacuum/water and Start of test: 5 min. 5 min. 5 min. 5 min. <br /> Test Start 1.rime(T,): 1:30pm 1:30pm 1:30pm 1:30pm <br /> Initial Reading(R, ): 12.500 in. 12.125 in. 12.250 in. 12.000 in. <br /> Test End Time CrF>; 2:30pm 2:30pm 2:30pm 2:30pm <br /> Final Reading(N): 12.500 in. 12.125 in. 12.250 in. 12.000 in. <br /> Test Duration(TF-T 1}: 1.00 hr. 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF.R1): 0.0000 in. 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: [K Pass ' ❑Fail J@ Pass Q Fail ®Pass „Q Fail ® Pass Fail <br /> Comments: Replaced 89&Diesel Fill Carps,87&89 0-rings.All tested good atter repairs. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby oeRify that all the Information contained in this report is true,acourate,and In full compliance with legal requirements. <br /> Technician's Signature: _ Dake:6/10/11 <br /> 1 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 />