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SWRCB, January 2006 <br />Spill Bucket1'ReportForm <br />F: <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1► 4 fVjENd DWI <br />Facility Name: Valero Date of Testing: 54-09 <br />Facility Address: 1605 S El Dorado <br />Facility Contact: Mr Angle Phone: (209) 939-1906 <br />Date Local Agency Was Notified of Testing: 48 Hr Prior Notice <br />Name of Local Agency Inspector (if present during testing): Ray Von Flu <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: HMC- Henderson Maint Co <br />Technician Conducting Test: Gavin Williams <br />Credentials': ❑ CSLB Contractor [X] ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 8016288 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />[X] Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Water <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />I-UNL <br />2- Supreme <br />3 4 <br />Bucket Installation Type: <br />X Direct Bury <br />Contained in Sump <br />X Direct Bury <br />❑ CoMmied in LunT <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />11" <br />11" <br />Bucket Depth: <br />11 °/4" <br />13" <br />Wait fitne between applying <br />vacuum/water and start of test: <br />1 Hr <br />1 Hr <br />Test Start Time (T�: <br />9:30a <br />9:30a <br />Initial Reading (&): <br />10 %4" <br />12" <br />Test End Time (TF): <br />10:30a <br />10:30a <br />Final Reading (RF): <br />10'/4" <br />12" <br />Test Duration (TF — T�: <br />1 Hr <br />1 Hr <br />Change in Reading (RF - RI): <br />0" <br />0" <br />Pass/Fail Threshold or <br />Criteria: <br />Pass <br />Pass <br />Test Result: <br />X " Pass ❑ Fail <br />X Pass "' ❑ Fail <br />❑ Pass ❑ Fait" ❑ Pass d Fail <br />COMM e®ts — (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 tee info ' n contain d ink report is true, accurate, and in full c e with legal re <br />quirensenix <br />Technician's Signature: Date: <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />a+aov Fw mn�n olrin Rma4 <br />