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0 0 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 /> Facility Name: EMIL'S LIQUOR& SPORT SHOP Date of Testing: 5/6/2015 <br /> Facility Address: 1405 CALFORNIA ST, ESCALON, CA 9 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:3/30/15 <br /> Name of Local Agency Inspector(ifpresent during testing): ELENA MAY 2 9 2015 <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRQN L <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112'FaVTN§TW61AV <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 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ® Direct Bury Direct Bury Direct Bury <br /> ❑ Direct Bury <br /> ❑Contained in ❑ Contained in <br /> Bucket Installation Type: <br /> El Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 3/4 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 0935 0935 0935 <br /> Initial Reading(Ri): 11 3/4 12-- 13 7/8 <br /> Test End Time(TF): 1035 1035 1035 <br /> Final Reading(RF): 11 3/4 12-- 13 7/8 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Z 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: 5-6-15 <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 />