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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: LOVES TRAVEL PLAZA Date of Testing: 08-10-16 Facility Address: 1533 COLONY RD RIPON CA 95366 phone: Facility Contact: KEVIN Date Local Agency Was Notified of Testing: 7-28-16 SAN JOAQUIN CO 9 Name of Local Agency Inspector (f present during testing): 2 TESTING CONTRACTOR INFORMATION ,�� r�n9� 744 0112 Fax (209) 744 0116 Company Name: AFFORDA TEST 416 2°° Street Galt, CA 95632 ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez Technician Conducting Test:5273934-UT 5249115 -UT 5263322 -UT 5263373 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Hydrostatic ❑ Vacuum ❑ Other Test Method Used: ® H y Equipment Test Equipment Used: TAPE / H2O Identify Spill Bucket (By Tank 111 87 Number, Stored Product, etc. C`ammentc — OPW BUCKETS 2 87 ® Direct Bury ❑ Contained in Sump 11 13 1000 12 1100 12 1 HOUR 0 on repairs made prior to 3 91 Resolution: 1/16 4 Z Direct Bury ❑ Contained in Sump 11 13 1000 12 1100 12 1 HOUR 0 and recommended Direct Bury Contained in CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Date:08-10-16 Technician's Signature: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. ®Direct Bury Bucket Installation Type: ❑ Contained in Sump Bucket Diameter: 11 ' Bucket Depth: 14 Wait time between applying _ vacuum/water and start of test: Test Start Time (Ti): 1000 Initial Reading (Ri): 13 Test End Time (TF): 1100 Final Reading (RF): 11 13 Test Duration (TF — Ti): I HOUR Change in Reading (RF - Ri): 0 Pass/Fail Threshold or Criteria: '1`pat Recnit: � Pass:: ,❑.Fail C`ammentc — OPW BUCKETS 2 87 ® Direct Bury ❑ Contained in Sump 11 13 1000 12 1100 12 1 HOUR 0 on repairs made prior to 3 91 Resolution: 1/16 4 Z Direct Bury ❑ Contained in Sump 11 13 1000 12 1100 12 1 HOUR 0 and recommended Direct Bury Contained in CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Date:08-10-16 Technician's Signature: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.