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MAO 0 9 205VRCB,January 2006 <br /> Spill Bucket Testing Report For��m���``IIp/'yp'R�e�� <br /> Thisform is intendedfor use by contractors performing annual testing of UST spill conPaeAt)lY1 E711rEW�'A.W form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submhtal[o the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: GEORGE'S MINI MART Date of Testing: 3-3-2015 <br /> Facility Address: 18662 N. HWY 88 LOCKEFORD, CA 95237 <br /> Facility Contact: Rupi Phone: <br /> Date Local Agency Was Notified of Testing:2/23/15 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury ®Direct Bury Direct Bury LA Direct Bury <br /> ❑ El Contained in ❑Contained in Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 14 13 13 1/2 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 9 9 9 9 <br /> Initial Reading(Rt): 13 12 13 13 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(Rr): 13 12 13 13 <br /> Test Duration(TF—T,): HR HR FIR HR <br /> Change in Reading(RF-R,): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑Fail ® Pass ❑Fail N 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 /> Te hnician's Signature Date: 3-3-2015 <br /> tate laws and regulations do not currently require testing to be performed by a qualified contractor.However,local <br /> requirements may be more stringent. <br />