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SWRCB, January 2006 <br />Spill Bucket Testing Deport 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 />Facility Name: ESTES EXPRESS Date of Testing: M rTrVjt,5, <br />Test Equipment Used: TAPE / H2O <br />Facility Address: 7611 S AIRPORT WAY STOCKTON CA 95206 <br />Facility Contact: JIMMY Phone: 209-982-1841 <br />Date Local Agency Was Notified of Testing :04-20-15 MAY 2 9 201b <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO CINDY V <br />GIV VliIUIVIVI�lV 'l t'1' <br />2, TESTING CONTRACTOR INFORMATION :.ACt`- U')C:VA074Ar:Nr <br />Company Name: AFFORDA TEST 416 2°, Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nm1mo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': Z ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Z Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1'16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />l DIESEL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />14 <br />- <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T): <br />945 <br />Initial Reading (R,): <br />14 <br />Test End Time (TF): <br />1045 <br />Final Reading (RF): <br />14 <br />Test Duration (TF — Tj): <br />I HOUR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />PASS <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass El Fail <br />Comments — (include information on repairs made prier to testing, and recommended.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: <br />Date:05-15-15 <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 />