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.ry.. n'L <br /> &WNJ,9a DJA 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 co`mp3 ted form and <br /> printouts from tests(ef applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SRH I Date of Testing: 5-24-16 <br /> Facility Address: 749E CHARTER WAY STOCKTON CA <br /> Facility Contact: JOHNNIE Phone: <br /> Date Local Agency Was Notified of Testing:5-19-16 <br /> Name of Local Agency Inspector(ifpresent during testing): FATINA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)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 /> Credentials: E ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 DSL 2 87 3 91 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation T e: ® ®Direct Bury ❑Direct Bu <br /> Direct Bury ®Direct Bury <br /> yP ry <br /> E] Contained in Sum ❑Contained in <br /> ❑Contained n <br /> Sump Contained in Sump Sum Sum <br /> Bucket Diameter: 11 1 I I 1 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(Ti): 10 10 10 <br /> Initial Reading(RI): 12 12 12.25 <br /> Test End Time(TF): 11 11 11 <br /> Final Reading(RF): 12 12 12.25 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ®..Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass <br /> ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> OPW FLAPPERS <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: V 6— aiDate 5-24-16 <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 />