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• ► SWRCB,January 2006 <br /> Shill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of LIST spill containment structures. The completed form and <br /> printoutsfr om 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: RANCHO SAN MIGUEL Date of Testing: 6130110 <br /> Facility Address: 1409 AIRPORT WAY STOCKTON, CA 95205 <br /> Facility Contact: GILBERT Phone: <br /> Date Local Agency Was Notified of Testing :6/3110 <br /> Name of Local Agency Inspector(ifpresent during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209)744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑ Lyle D. Nimmo E Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials`: 2 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: 1116" <br /> 7 <br /> Identify Spill Bucket (By Tank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: Contained in El Contained in <br /> Contained in Sump ❑ Contained in Sump . Sump Sum <br /> Bucket Diameter: 11 I I <br /> Bucket Depth: 15 13 314 <br /> Wait tune between applying <br /> vacuum/water and start of test: - '- <br /> Test Start Time(Ti): 0920 0920 <br /> Initial Reading(Rr): 133/4 117/8 <br /> Test End Time(TF): 1020 1020 <br /> Final Reading(RF): 13 3/4 11 718 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-R3): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- -- - <br /> Test Result: Pass ❑ Fail 0 Pass ❑ Fail E Pass ❑ Fail Z Pass ❑ Fail <br /> Comments— (include inforrnation on repairs made prior to testing, and recomrnerzded follow-tip 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: <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 />