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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 />FACILITV INFORMATION <br />Facility Name: VALLEY SERVICE STATION ARCO =ate 12-I S-1 1 <br />Facility Address: 16 EAST HARDING WAY STOCKTON CALIFORNIA 95204 <br />Facility Contact: ABRAHAM Phone: 209-466-9516 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO JEFF WONG <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fak: (209) 744-01 l6 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix 6. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 527334 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3_ SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum Other <br />Test Equipment Used: TAPE / I -I20 Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 87 <br />3 89 <br />491 <br />Bucket Installation Type: <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />® Contained in <br />Sump <br />❑ Direct Bury <br />®Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />I 1 <br />1 I <br />Bucket Depth: <br />14 <br />14 <br />11 <br />12 1/2 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />_ <br />- <br />Test Start Time (TI): <br />1100 <br />1100 <br />1100 <br />1100 <br />Initial Reading (RI): <br />13 <br />13 <br />10 <br />111/2 <br />Test End Time (TF): <br />1415 <br />1415 <br />1415 <br />1415 <br />Final Reading (RF): <br />13 <br />13 <br />10 <br />11 1/2 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - R,): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />Comments — (include inlo)rmation on repairs made prior to testing, and rccoinrne17ded.16lloly-r(p_forwiled tests) <br />QPW SPILL BUCKETS. 87 IS A QUAD FILL SUMP <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:12-15-11 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, ocal requirements <br />may be more stringent. <br />