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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: <br /> Facility Address: 1533 COLONY RD RIPON CA 95366 I�11 <br /> Facility Contact: KEVIN Phone: <br /> Date Local Agency Was Notified of Testing:7-17-15 <br /> Name of Local Agency Inspector(fpresent during testing): STACY ENVIRnAlA <br /> II'rtj r1Cpn gTA/It"�tI, <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: ❑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 BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identi Spill Bucket B Tank 1 DIESEL NORTH 2 DI <br /> Identify p ( y DIESEL SOUTH 3 � 4 <br /> Number, Stored Product, <br /> ❑Direct Bury ❑Direct Bury Direct Bury L]Direct Bury <br /> Bucket Installation Type: El Contained in <br /> ® Contained in Sump ®Contained in Sump ❑Contained in <br /> Sump 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(T): 1103 1103 <br /> Initial Reading(RO: 13 12 <br /> Test End Time(TF): 1103 1103 <br /> Final Reading(RF): 13 12 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E 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:08-11-15 <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 />