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RECFIVED <br /> 12018 <br /> SWRCB , January 2006 <br /> Spill Bucket Testing Report FordVIRONMENTAL HEALTH <br /> This form is intended for use by contractors petforming annual testing of UST spill containment st� ijeted form and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal o t e local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Fast & Easy #103 Date of Testing : 12/03/2018 <br /> Facility Address : 8660 Lower Sacramento Road Stockton 95212 <br /> Facility Contact: Asim Phone : (707) 393-9859 <br /> Date Local Agency Was Notified of Testing : 11 /29/2018 <br /> Name of Local Agency Inspector (tf present during testing) : <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name : Confidence UST Services , Inc. <br /> Technician Conducting Test: Austin Sterling <br /> Credentials ' : CSLB Contractor EIICC Service Tech. SWRCB Tank Tester Other (Spec) <br /> License Number(s) : 804904 8339953 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑✓ Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : Lake Test Equipment Resolution : 0 . 0625" <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number, Stored Product, etc. Regular Premium Diesel <br /> Bucket Installation Type : 0 Direct Bury 0 Direct Bury 0 Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sum <br /> Bucket Diameter: 12.00" 12.00" 12.00" <br /> Bucket Depth: 12.00" 12.00" 12.00" <br /> Wait time between applying <br /> 5 min 5 min 5 min <br /> vacuum/water and start of test : <br /> Test Start Time (Ti) : 2:00 pm 2:00 pm 2:00 pm <br /> Initial Reading (Rr) : 8.00" 8.00" 8.00" <br /> Test End Time (TF) : 3 :00 pm 3:00 pm 3:00 pm <br /> Final Reading (RF) : 8.00" 8.00" 8A0" <br /> Test Duration (TF — Ti) : 1 hour 1 hour 1 hour <br /> Change in Reading (RF - RI) : 0.00" 0.00" 0.00" <br /> Pass/Fail Threshold or 0.0625 0.0625 0.0625 <br /> Criteria: <br /> Test Result: 0 Pass ❑ Fail 0 Pass ❑ Fail 0 Pass ❑ Fail ❑ 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 information contained in this report is true, accurate, and in full compliance with legal requirements. <br /> Technician' s Signature : eig Date: 12/03/2018 <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 />