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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(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: GEORGE'S MINI MART Date of Testing: 3/10/14 <br /> Facility Address: 18662 N. HWY 88 LOCKEFORD, CA 95237 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:2/17/14 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS CACAPIT & WILLIE <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 /> ®Direct Buryury <br /> Direct B <br /> F Bucket Installation T Contained in El® Duect Bury ® Direct Bury Contained in <br /> El Contained in Sump El Contained in Sump ❑ <br /> SUMPSum <br /> Bucket Diameter: I I 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,): 0924 0924 0924 0924 <br /> Initial Reading(R,): 13 12 12 1/2 13 <br /> Test End Time(TF): 1024 1024 1024 1024 <br /> Final Reading(RF): 13 12 12 1/2 13 <br /> Test Duration(TF—T,): HR HR HR HR <br /> Change in Reading(RF-R,): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: IL ® Pass ❑ Fail I ® Pass ❑Fail I ® Pass ❑ Fail I ® Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up far 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: 3-10-14 <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 />