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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: A. G. SPANOS JET CENTER Date of Testing: 2-19-13 <br /> Facility Address: 4800 S. AIRPORT WAY STOCKTON, CA 95206 <br /> Facility Contact: THOMAS Phone: <br /> Date Local Agency Was Notified of Testing:1/15/13 <br /> Name of Local Agency Inspector(if present during testing): MUNI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d Street Galt,CA 95632 (2.09)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 /> LC:r:ed:entials': ® ICC Service Tech. F 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 (Bv Tunk 1 JET A NORTH 2 JET A MIDDLE 3 JET A SOUTH 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ❑ Direct Bury <br /> YP L] Contained in <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury E] Contained in <br /> ❑ Contained in Sump ® Contained in Sump <br /> Sump Sump <br /> Bucket Diameter: 11 I 1 11 <br /> Bucket Depth; 14 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(Ti): 0935 0935 0935 <br /> Initial Reading(Ra): 13 13 12 <br /> Test End Time(TF): 1035 1035 1035 <br /> Final Reading(RF): 13 13 12 <br /> Test Duration(TF—Ti): HR HR HR FIR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: " -- <br /> Test Result: 0 Pass ❑ Fail ® Pass ❑ Fail E Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed testa) <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 Ovo<t�— Date: 2-19-13 <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 />