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nECENcD <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form AUG 2 1 2018 <br /> This form is intended for use by contractors performing annual testing of UST spill containment str tted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submit, ante <br /> Wgency. <br /> HEALTH C - <br /> 1. FACILITY INFORMATION <br /> Facility Name: LOVES TRAVEL PLAZA Date of Testing: 08-09-18 <br /> Facility Address: 1533 COLONY RD RIPON CA 95366 <br /> Facility Contact: KEVIN T Phone: <br /> Date Local Agency Was Notified of Testing:06-28-18 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez ❑ Ed Stearns <br /> #8883064-UT #8883059-UT #8883072-UT #8883080-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> "Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: I/16 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ®Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Contained in ❑ Contained in <br /> F1 Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 14 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1200 1200 1200 <br /> Initial Reading(Rj): 13 12 12 <br /> Test End Time(TF): 1300 1300 1300 <br /> Final Reading(RF): 13 12 12 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result I ® Pass El Fail ® Pass El Fail ® Pass ❑ Fail El Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and rcconrniendedfolloir-up,forfailed tests) <br /> OP W BUCKETS <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:08-09-18 <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 />