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IE SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and
printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Shell I Date of Testing: 9/24/10
Facility 4700 Coffee Bakersfield,CA 93308
Facility Contact: Matt Jeffries Phone: 661-496-7006
Date Local Agency Was Notified of Testing: 8/26/2010
Name of Local Agency Inspector(fpresent during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services,Inc.
Technician Conducting Test: Bryan A Self
Credentials: ❑x CSLB Contractor Z ICC Service Tech. ❑SWRCB Tank Tester ❑Other (Specify)
License Number(s): CSLB# 804904 ICC# 8022804-UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: 0 Hydrostatic ❑Vacuum ❑Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625'
Identify Spill Bucket(By Tank 1 South Regular Fill 2 3 4
Number, Stored Product, etc.)
Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury
0 Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum
Bucket Diameter: 13.00"
Bucket Depth: 12.00"
Wait time between applying 5 Min.
vacuum/water and start of test:
Test Start Time(Tj): 9:15 am
Initial Reading(Rj): 10.00"
Test End Time(TF): 10:15 am
Final Reading(RF): 10.00"
Test Duration (TF—Ti): 1 Hour
Change in Reading(RF-R,): 0.00"
Pass/Fail Threshold or 0.0625'
Criteria:
Test Result _ ?' ® Pass ❑RFail ® Pass 1 k® Pas`s, DF ' (3 Pass®Fail
Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is trueya4wurate,and in full compliance with legal requirements.
Technician's Signature: Date: 9/24/2010
State laws and regulations do not currently requir testing to be performed by a qualified contractor.However,local requirements
may be more stringent.
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• o�.. Invoice No.: 24436
Site: Shell
4700 Coffee Rd
Bakersfield, CA 93308
Repairs Requested: Retest the Regular south fill spill bucket, and retest the
relay for the super turbine.
Repairs completed: I first had to wait because when I arrived on site there
was a fuel drop. I then shut down the site and verified that the super relay was
replaced and functioning properly. After the fuel truck left I then ran a lake test
and verified the spill bucket was passing.
Required Repairs, Still Pending:
Technician Name: Bryan A Self
Signature:
Date: 09-24-10
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• Invoice No.: 24436
Site: Shell
4700 Coffee Rd
Bakersfield, CA 93308
Repairs Requested: Replaced the Regular south fill spill bucket
Repairs completed:
Required Repairs, Still Pending:
Technician Name: Bryan A Self
Signature: A, &L
Date: 08-26-10