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RECELVED006 <br />Spill Bucket Testing Report Form NOV 0 7 20,3 <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 submittaENIVj"r4#&"r!cy. <br />1. FACILITY INFORMATION HEALTH DEPARTMENT <br />Facility Name: TOYS R US I Date of Testing: 10-2-13 <br />Facility Address: 1624 ARMY CT STOCKTON CA <br />Facility Contact: Tony Evans Phone: 209-465-4912 <br />Date Local Agency Was Notified of Testing :9-11-13 <br />Name of Local Agency Inspector (rf present during testing): Stacy <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo E David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />II Credentials`: E ICC Service Tech. E SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O & TAPE MEASURE Equipment Resolution: 1/16 <br />Identify Spill Bucket (lay Tank <br />Number, Stored Product, etc.) <br />1 DSL <br />2 <br />3 <br />4 <br />Bucket Installation Type:[—] <br />E Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />r_1 Contained in Sump <br />❑ Direct Bury <br />Contained in <br />Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />12 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA <br />Test Start Time (Ti): <br />945 <br />Initial Reading (Ri): <br />11 <br />Test End Time (TF): <br />1045 <br />Final Reading (RF): <br />11 <br />Test Duration (TF — Tj): <br />1 HR <br />Change in Reading (RF - Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />Test Result: <br />E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />E Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up, for failed tests) <br />Replaced OPW drain and fill adapter to pass test <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Tc__�_j <br />Date 10-2-2013 <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 />