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EGLIVEL) <br />OCT 3 9 2 j)vRCB, January 2006 <br />Spill Bucket Testing Report Form �M <br />This form is intended for use by contractors performing annual testing of UST spill contEMUMM tT feted form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for suMFAi2WFPtRRWffatory agency. <br />1_ FAC'.TT,TTV INFORMATION <br />Facility Name: TOYS R US I Date of Testing: 10/9/2015 <br />Facility Address: 1624 ARMY COURT STOCKTON , CA 95206 <br />Facility Contact: TONY Phone: <br />Date Local Agency Was Notified of Testing :9/22/2015 <br />Name of Local Agency Inspector (ifpresenl Charing Ics[ing): STACY AND VICKY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL RUCKF,T TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />3 4 DIESEL <br />Identify Spill Bucket (By `l unk <br />Number, Stored Product, etc. <br />1 <br />2 <br />Bucket Installation Type: <br />❑ Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />El Contained in <br />Sump <br />® Direct Bury <br />❑ 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 />Test Start Time (Tj): <br />1130 <br />Initial Reading (R,): <br />11 - <br />Test End Time (TF): <br />1230 <br />Final Reading (RF): <br />11 - <br />Test Duration (TF —Tj): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF -R,): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />® 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 Date: 10-9-15 <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 />