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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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 submittal to the local regulatory agency. <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 Phone: <br /> Date Local Agency Was Notified of Testing:08-09-18 <br /> Name of Local Agency Inspector(tf present during testing): JESSIE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez ❑ Edward Stearns <br /> Technician Conducting Test: <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: 1/16 <br /> Identify Spill Bucket(By Tank 1 DIESEL NORTH 2 DIESEL SOUTH 3 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> ® Contained in Sump ®Contained in Sump El Contained in ❑Contained inSum Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1200 1200 <br /> Initial Reading(RI): 13 12 1 IL <br /> Test End Time(TF): 1300 1300 UG 2 <br /> Final Reading(RF): 13 12 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR E 1R0 <br /> NMM MIL <br /> Change in Reading(RF-Rj): 0 0 HEM ` <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass [:] Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW 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 />