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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> prinioutsfrom tests(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SRH MARKET US GASOLINE Date of Testing: 05-31-11 <br /> Facility Address: 749 E CHARTER WAY STOCKTON CA <br /> Facility Contact: JOHNNY Phone: 209465-8979 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO STACY <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 ❑ 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 ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bury ®Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑ Contained in Sump ❑Contained in Sump <br /> SumpSum <br /> Bucket Diameter: 11 I 1 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: - <br /> Test Start Time(T,): 1400 1400 1400 <br /> Initial Reading(R,): 11 7/8 12 1/8 12 5/8 <br /> Test End Time(TF): 1500 1500 1500 <br /> Final Reading(RF): 117/8 12 1/8 125/8 <br /> Test Duration(Tr—T,): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: - <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑ Fail <br /> COMMents—(include information on repairs made prior to testing and recommendedfollow-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:05-3 1-11 <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 />