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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SRH Date of Testing: 5-2-2012 <br /> Facility Address: 749 E C14ARTER WAY STOCKTON CA <br /> Facility Contact: JOHNNY Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 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: 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 /> ® Direct Bury ®Direct Bury ® Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Contained in E] Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Star[Time(Ti): 9 9 9 <br /> Initial Reading(RI): 12 12 12.25 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 12 12 12.25 <br /> Test Duration(TF—Ti): IHR IHR IHR <br /> Change in Reading IRF-Ri): 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 ❑ 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: V z ` � Date 5-2-12 <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 />