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0 0 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 (rf applicable), should be provided to the facility owner/operator far submittal to the local regulatory ogengi). <br /> 1. FACILITY INFORMATION <br /> Facility Name: SRH I Date of Testing: 5-26-2010 <br /> Facility Address: 749 E CHARTER WAY STOCKTON CA <br /> Facility Contact: J014NY Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency inspector(rfpresent during testing): RAY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116_ <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo 0 David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. 0 SWRCB Tank Tester <br /> 3. SPILT.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 l 87 -- 2 89 3 91 �— 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Contained in [] Contained in <br /> L1 Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 1 I i 1 I I <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 9 <br /> Initial Reading(111): 12 12.25 12 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 12 12.25 12 <br /> Test Duration(TF—Tt): IHR IHR IHR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1116 1/16 1116 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ElFail ® Pass El Fail ❑ Pass El Fail <br /> Comments— (include information on repairs made prior 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: Date 5-26-10 <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 />