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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use bytractors conshould be roorming annual testing of UST vided to the fac ility owner/operator for ill submittainment structures. <br />to the local regulatory agency. and <br />printouts from tests (if applicable), provided <br />1. FACILITY INFORMATION <br />Fty Name: <br />Date of Testing: 08-10-16 <br />aciliLOVES TRAVEL PLAZA <br />Facility Address: 1533 COLONY RD RIPON CA 95366 <br />Facility Contact: KEVIN Phone: <br />Date Local Agency Was Notified of Testing :7-28-16 VICKY <br />Name of Local Agency Inspector (if present during testing): <br />Mdl�aq 2. TESTING TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 21 Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler E Felix G. Ramirez <br />Technician Conducting Test: 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': E ICC Service Tech. E SWRCB Tank Tester <br />Test Method Used: IZS <br />Test Equipment Used: TAPE / H2O <br />3. SPILL BUCKET TESTING INFORMATION <br />uirnctntlC n Vacuum ❑ Other <br />Identify Spill Bucket (By Tank I DIESEL NORTH <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />Bucket Diameter' I <br />Bucket Depth: — <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (RI): <br />Test End Time (TF): <br />Final Reading (RF): <br />TestEDuration (TF — Ti): <br />ChaReading (RF - Ri): <br />Pass/Fail Threshold or <br />Criteria: <br />❑ Direct Bury <br />E Contained in Sump <br />11 <br />14 <br />1000 <br />13 <br />1100 <br />13 <br />1 HOUR <br />0 <br />11 <br />13 <br />1000 <br />12 <br />1100 <br />12 <br />1 HOUR <br />0 <br />Test Result: <br />E P8S5 :a Fu!I IN raSS' s, ,_ } rau <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <br />is. <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 />Date:08-10-16 <br />Technician's Signature: <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 />