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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 /> FFFacilityName: LOVES TRUCK CENTER Date of Testing: 8/11/10 <br /> Address: 1533 COLONY RD. RIPON, CA 95366Contact: KIM& KEVINPhone:DateLocal Agency Was Notified of Testing:5/14/10 -- -- <br /> Name of Local Agency Inspector(ifpresent during testing): MUNI &TWI =_- <br /> 2. TESTING CONTRACTOR INFORMATION _— <br /> [Te7chnician <br /> me: AFFORDA TEST 416 2"d Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> onducting 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 ❑ Vacuwn ❑ 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 /> ❑ Direct Bury ❑ Direct Bury <br /> E] Direct Bury ❑ Direct Bury ® Contained in El Contained in <br /> Bucket Installation Type: ® Contained in Sump ® p Sum Contained in Sum Sum <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 /> 1230 1230 1230 <br /> Test Start Time(Ti): 10 1/2 <br /> Initial Reading(R,): 11 I17/8 1330 <br /> Test End Time(TF): 1330 1330 ------ <br /> Final Reading(RF): 11 117/8 10 1/2 HR <br /> HR <br /> Test Duration(TF—T,): HR HR -- <br /> Change in Reading(RF-Rl): 0 0 0 _ <br /> Pass/Fail Threshold or -- -- <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail Pass El ® Pass ❑ Fail El 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:8/1 1/10 <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 />