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` 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 /> F <br /> ty Name: RANCHO SAN MIGUEL Date of Testing: 6-24-09 <br /> ty Address: 1409 AIRPORT STOCKTON CA <br /> ty Contact: GILBERT Phone: <br /> eLocal Agency Was Notified of Testing:RAY <br /> Name of Local Agency Inspector (if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209)744-0112 Fax: (209) 744-0]16 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo 9 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: 1420& TAPE MEASURE Equipment Resolution: 1116 <br /> Identify Spill Bucket(By Tank 1137 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑� Contained in d Contained in Contained in Sump [9Contained in Sump Sum Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 12 <br /> Wait time between applying NA <br /> vacuum/water and start of test: NA <br /> Test Start Time(TI): 1100 1100 <br /> Initial Reading(R[): 12 10 <br /> Test End Time(TF): 1200 1200 <br /> Final Reading(RF): 12 10 <br /> Test Duration(TF—Tj): I HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass ail Threshold or 1116 U16Criteria: <br /> Test Result: ❑ Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail <br /> Comments — (include information on repairs made prior to testing, and 1•ecommended 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: W Date: 6-24-09 <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 />