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,.r <br />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 (japplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />T FA/`i7 iTV FNL`/iDMATiAIU <br />Facility Name: MIRACLE MILE MART Date of Testing: 8-26-2014 <br />Facility Address: 244 W HARDING WAY STOCKTON CA <br />Facility Contact: RAY I Phone: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />Date Local Agency Was Notified of Testing <br />3 DSL <br />4 <br />Name of Local Agency Inspector (ifpresent during testing): JEFF SJV <br />.11,- V V LVID <br />Company Name: AFFORDA TEST 416 2"a Street Galt, CA 95632 (209) 744"4Q11i�! <br />1k WT <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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPIId, RTICKFT TF.STTNC. TNVORMATT(1N <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br />- <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />ED Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />®Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />i l <br />11 <br />1 I <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />-- <br />Test Start Time (T,): <br />235 <br />235 <br />Initial Reading (R,): <br />12.59 <br />12 <br />Test End Time (TF): <br />335 <br />335 <br />Final Reading (RF): <br />12.50 <br />12 <br />14.40 <br />Test Duration (TF —Ti): <br />1HR <br />IHR <br />IIiR <br />Change in Reading (RF -R,): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommendedfollow-upforfailed tests) <br />OPW FLAPPERS <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: if ' —j <br />Date 8-26-2014 <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 />