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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(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: ESTES EXPRESS I Date of Testing: 05-27-11 <br /> Facility Address: 7611 S AIRPORT WAY STOCKTON CA 95206 <br /> Facility Contact: Phone: 209-982-1841 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO MICHELLE HENRY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2vd Street Galt,CA 95632 (209)744-0112 Fax: (209)7440116 <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 Ll Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 DIESEL 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury ❑Direct Bury Direct Bury Lj Direct Bury❑ ❑Contained in F-1 Contained inContained in Sump Contained in Sump Sump Sum <br /> Bucket Diameter: I1 <br /> Bucket Depth: 14 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 1500 <br /> Initial Reading(Ri): 137/8 <br /> Test End Time(TF): 1600 <br /> Final Reading(RF): 137/8 <br /> Test Duration(TF—Tj): 1 HOUR <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or PASS <br /> Criteria: <br /> Test Result: I ® Pass ❑Fall ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass [:]Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> HAD TO TIGHTEN RING ON RISER <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 /> t� <br /> Technician's Signature: Q Date:05-27-11 <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 />