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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: EMIL'S LIQUOR AND SPORTS I Date of Testing: <br /> Facility Address: 1405 CALIFORNIA ST ESCALON CA 95320 <br /> Facility Contact: ALI I Phone: 209-838-7674 <br /> Date Local Agency Was Notified of Testing:04-14-14 PA" 3 V 2,U4 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO ELENA <br /> ENVIKUNMt <br /> 2. TESTING CONTRACTOR INFORMATION HEALTH DEPARTMENT <br /> Company Name: AFFORDA TEST 416 2nd 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury Duect Bury E] Direct Bury <br /> Bucket Installation Type: ❑Contained in L1 Contained in <br /> E] Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 12 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1200 1200 1200 <br /> Initial Reading(R,): 12 12 14 <br /> Test End Time(TF): 1300 1300 1300 <br /> Final Reading(RF): 12 12 14 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R,): 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:05-06-14 <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 />