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r <br /> s � <br /> 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: PAA Date ofTesting: 6-22-2011 <br /> Facility Address: 1409 AIRPORT WAY STOCKTON CA <br /> Facility Contact: GILBERT Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): STACY <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 Z David A.Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentialsl: Z ICC Service Tech, E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By kink 1 87 2 91 3 4 <br /> Number, Stored Product, elcj <br /> Direct Bu Direct Bu <br /> Bucket Installation Type: <br /> E]Direct Bury ❑ Direct Bury Bury Bury <br /> yp ® Contained in Sump Z Contained in Sump ❑Contained in El Contained in <br /> Sump Sum <br /> Bucket Diameter: 1 I 11 11 <br /> Bucket Depth: 14 12 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(Ti): 1 1 <br /> Initial Reading(Rl): 12.50 11 <br /> Test End Time(TF): 2 2 <br /> Final Reading(RF): 12.50 11 <br /> Test Duration(TF—Tt): 1118 IHR 1HR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: M Pass ❑ Fail M Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, acid 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:g Date 6-22-1I <br /> t 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 />