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i <br /> MAY 0 9 SMCB,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. THA,fpleted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the/oca/. latory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: EMIL'S LIQUOR AND SPORTS Date of Testing: 05-03-11 <br /> Facility Address: 1405 CALIFORNIA ST ESCALON CA 95320 <br /> Facility Contact: LINDA Phone: 209-838-7674 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO Muni <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 N Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H20 Equipment Resolution: 1/I6 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury N Direct Bury N Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 1 I I I <br /> Bucket Depth: 12 12 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 900 900 900 <br /> Initial Reading(Rt): 11 1/4 11 1/8 13 1/4 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 11 1/4 11 1/8 13 1/4 <br /> Test Duration(TF—Tt): 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-R): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑Fail N Pass ❑ Fail `' N 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:05-03-11 <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 />