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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(fapplicable), should be provided to the facility ownerloperator 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:6/3/10 <br /> Name of Local Agency Inspector(if present 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 ® 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 89 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑ Direct Bury <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in <br /> ® Contained in Sump ❑ Contained in Sump ❑ Contained in <br /> Sump Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 15 133/4 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(Ti): 0920 0920 <br /> Initial Reading(Rj): 133/4 117/8 <br /> Test End Time(TF): 1020 1020 <br /> Final Reading(RF): 13 314 <br /> 117/8 <br /> Test Duration(TF—Tj): FIR HR HR ITR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- -- -- <br /> Test Result: jj ❑ Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fall <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for jailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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 />