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RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form AUG 2 3 2013 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The com let orm and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submitfiNVAM ncy. <br /> HEALTH DEPARTMENT <br /> 1. FACILITY INFORMATION <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): ELAINA <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 E Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (4y Tank 1 DIESEL T1 2 DIESEL T2 3 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in [:1 Contained in <br /> E Contained in Sump E Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1000 1000 <br /> Initial Reading(111): 13 12 1/2 <br /> Test End Time(TF): 1100 1100 <br /> Final Reading(RF): 13 12 1/2 <br /> Test Duration(TF—Tj): HR HR HR I-I R <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E Pass ❑Fail E 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: e 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 />