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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(rfpresent dzning 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: ® 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 DIESEL TANK 1 2 DIESEL TANK 2 3 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑ Direct Buy ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ® Contained in Sump ® Contained in Sump Sum Sum <br /> Bucket Diameter: I 1 1 1 <br /> Bucket Depth: 15 15 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1015 1015 <br /> Initial Reading(R1): 14 14 1/2 <br /> Test-End Time(TF): 1115 1115 <br /> Final Reading(RF): 14 14 1/2 <br /> Test Duration(TF—Tj): HOUR HR <br /> [Pass/Fail <br /> hange in Reading(RF-Rj): 00 00 <br /> Threshold or <br /> riteria: <br /> est:Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing and z•ecommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inform n ntomed-in-t is report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: -"`W <br /> 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 />