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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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.FACILITY INFORMATION <br /> Facility Name:DKS INVESTMENTS Date of Testing:5/3/2018 <br /> Facility Address:9484 WEST LANE WEST LANE CHEVRON,STOCKTON,CA 95210 <br /> Facility Contact:KARAM SINGH Phone:209-814-8581 <br /> Date Local Agency Was Notified of Testing:4/30/2018 <br /> Name of Local Agency Inspector(ifpresent during testing):UNKOWN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials): r CSLB Contractor r ICC Service Tech. ❑ SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank 1 Spill Box#Tank 2 Spill Box#Tank 3 Diesel- <br /> Identify Spill Bucket(By Tank UNLEADED-Fill 1-Direct PREMIUM-Fill 1 -Direct- Fill 1-Direct-Below Grade Spill Box# <br /> Number, Stored Product, etc.) -Below Grade m Below Grade m <br /> containment sump containment sump in containment sump <br /> C' Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: r. Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 17.00 16.00 16.00 <br /> Wait time between applying 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(Ti): 10:00:00 10:00:00 10:00:00 <br /> Initial Reading(Rl): 17.00 in.H2O 16.00 in.H2O 16.00 in.H2O <br /> Test End Time(TF): 11:00:00 11:00:00 11:00:00 <br /> Final Reading(RF): 17.00 in.H2O 16.00 in.H2O 16.00 in.H2O <br /> Test Duration(Tp-TI): 1 hr 1 hr 1 hr <br /> Change in Reading(Rp-RI): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Pass Pass <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 /> hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: �—1px_ Date: 5/32018 <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2336205 <br />