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1 lww 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: RIVER POINT MARINA — <br /> Date of Testing: 1-8-10 <br /> Facility Address: 4950 BUCKLEY COVE WAY STOCKTON,CA 95269 <br /> Facility Contact: RICH Phone: 209-951-4144 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2e"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 (6r Tank 1 89 2 RED DIESEL 3 4 <br /> Number, Stared Product, etc. <br /> ® ❑ <br /> Direct Bury ® Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ElContained in ❑Contained in <br /> ElContained in Sump ElContained in Sump sumpSum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 15 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 0930 0930 <br /> Initial Reading(Rj): 143/8 103/4 <br /> Test End Time(TF): 1030 1030 <br /> Final Reading(RF): 143/8 103/4 <br /> Test Duration(TF—Tj): HR HR <br /> Change in Reading(RF-Rj): 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/or%ailed 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: I Date: 1-8-10 <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 />