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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: LOVES TRUCK PLAZA I Date of Testing: 8/11/09 <br /> Facility Address: 1553 COLONY RD. RIPON,CA 95366 <br /> Facility Contact: KEVIN Phone: <br /> Date Local Agency Was Notified of Testing :7/3/09 <br /> Name of Local Agency Inspector(ifpresent during testing): MUNI <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: Z ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE , H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 MAIN 2 87 SYPHON 3 91 4 <br /> Number, Stared Product, etc.) <br /> ❑YP Direct Bury ❑ Direct Bury <br /> ® <br /> Bucket Installation Type: <br /> El Direct Bury ❑ Direct Bury Contained in Sump ® Contained in Sump ® Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 1 1 1 1 1 I <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:30 930 930 <br /> Initial Reading(Rj): 11 1/2 113/4 11 1/2 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 11 1/2 113/4 11 1/2 <br /> Test Duration(TF—Ti): HR HR HR <br /> Change in Reading(RF-Rj): 00 00 00 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass <br /> ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inform ntained-in_this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: <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 />