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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(tf 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 CENTER I Date of Testing: 8/11/11 <br /> Facility Address: 1533 COLONY RD. RIPON, CA 95366 <br /> Facility Contact: KIM&KEVIN Phone: <br /> Date Local Agency Was Notified of Testing:7/7/11 <br /> Name of Local Agency Inspector(fpresent during testing): MUNI&JEFF WONG <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d 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-LT 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 87 2 87 SLAVE 3 91 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury Direct Bury <br /> Direct Bury Direct Bury <br /> ® Contained in Sump ®Contained in Sump Su Contained in El Contained in <br /> SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 13 13 <br /> Wait time between applying _- -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1015 1015 1015 <br /> Initial Reading(Rj): 13 12 11 1/2 <br /> Test End Time(TF): 1115. 1115 1115 <br /> Final Reading(RF): 13 12 11 1/2 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 777 <br /> Test Result: `Pass ❑°F��I, ';' ®;,Vass - ❑°Fail„, Pass :' ❑ Fail. ❑ Pass ❑ 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 information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 8/11/11 <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 />