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A <br />0 <br />, <br />SWRCB, January 2006 <br />' ort Form !sled f©rm and <br />Spill Bucket Testing hep ulatory agency. <br />o UST spill containment structures. The comp <br />er orming annual testing erator for submittal to the local reg <br />or use by contractors p acili owner/op <br />This form is intendedfor should be provided to the f t1' <br />printouts from tests (if applicable), ATION 05-05-14 <br />1. FACILITY INFORM Date of Testing: <br />Name: ESTES EXPRESS <br />Facility 7611 S AIRPORT WAY STOCKTON CA 95206 Phone: 209-982-1841 <br />Facility Address: JIMMY <br />Facility Contact: p4-14-14 SAN JOAQUIN CO ELENA <br />Date Local Agency Was Notified of Tresent during testing): <br />Name of Local Agency inspector (if p <br />G CONTRACTOR INFORMATlO l2 Fax: (209) 744-0116 <br />Z. TESTINp9} 744-01 <br />2 <br />Company Name: <br />AFFORDA TEST 416 2"d Street Galt, CA 9563 Felix G. Ramirez <br />F-1DavidA. Winkler 934 -UT <br />Technician Conducting Test: <br />Credentials': 2 iCC Service Tech <br />VN <br />Test Method Used: <br />Test Equipment Used: TAPE I HZ , <br />1 DIES' <br />Spill Bucket (BY Tank <br />Identify <br />Number, Stored Product, etc.) <br />Bucket installation Type <br />Bucket Diameter: <br />Bucket Depth: <br />' Wait time between applying <br />vacuurnlwater and start of test: <br />Test Start Time JO, <br />initial Reading (RI): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF — Ta): <br />Change in Reading (RF - Ra): <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />—_(include info <br />Comments! <br />Q Zane A. Nimmo 5273 <br />Lyle D. Nimmo 5263373 -UT ---- <br />5249115 -UT 5263322 -UT <br />_ 1 <br />® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING <br />FORMATION <br />Q Vacuum <br />0 Other <br />Hydrostatic Equipment Resolution: 116 <br />0 Direct Bury <br />0 Contained in Sump <br />11 <br />14 <br />900 <br />14 <br />1000 <br />14 <br />1 HOUR <br />l0 <br />PASS <br />Z Pass ❑ Fail <br />on repairs made <br />3 4 <br />2 <br />Direct Bury ' Direct Bury <br />a Contained in <br />Direct Bury Contained in Sum <br />Contained in Sump Sunip. <br />® Pass ❑Fail 1 ::'' Pass a Fail 1 L Pass E] Fail <br />to testing, and recommend-,Jjollow-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 />Date:05-05-14 <br />i <br />Technician's Signature: <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 />