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Tv:rr <br /> ` S W RC B, ,January 2006 <br /> Spill Bucket Testing Report Form F 2 3 2013 <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 sSNV4�4 ► r tory agency. <br /> 1.FACILITY INFORMATION HEAL!,,-;DEPARTMENT _ <br /> Facility Name: LOVES TRUCK PLAZA Date of Testing: 8/13/13 <br /> Facility Address: 1533 COLONY RD. RIPON, CA 95366 <br /> Facility Contact: KIM&KEVIN Phone: <br /> Date Local Agency Was Notified of Testing:7/23/13 <br /> Name of Local Agency Inspector(if present during testing): ELENA <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-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 87 2 87 SLAVE 3 91 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: I 1 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—Tl): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® 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 /> 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: 8-13-13 <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 />