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9 • 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(if applicable),should be provided to the facility ownerfoperator far submittal to the local regulatory agency. <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: JOHNY Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): RAY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°d 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 /> Credentialsl: 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: 1116 <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in C]Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I 1 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T4): 9 9 9 <br /> Initial Reading(R[): 12 12.25 12 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 12 12.25 12 <br /> Test Duration(TF—Ti): 1HR l HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: Z Pass ❑ Fail Z Pass ❑Fail ® Pass ❑ Fail ❑ Pass ❑ 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 /> Tcl� <br /> Technician's Signature: Date 5-26-10 <br /> 1 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 />