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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(ifopplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SJ RTD I Date of Testing: 05-15-13 <br /> Facility Address: 1535 E LINDSAY ST STOCKTON CA 95205 <br /> Facility Contact: DOUG Phone: 209-467-6671 <br /> Date Local Agency Was Notified of Testing:04-16-13 <br /> Name of Local Agency Inspector(ifpresenl daring testing): SAN JOAQUIN CO.JEFF WONG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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/1-120 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank I BLDI 2 BLD 2 3 BLD 3 4 <br /> Number, Stored Product, etc. <br /> ❑Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Direct Bury El Direct Bury ® Contained in El Contained in <br /> ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 12 12 12 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1100 1100 1100 <br /> Initial Reading(R,): 11 11 11 <br /> Test End Time(TF): 1200 1200 1200 <br /> Final Reading(RF): 11 11 11 <br /> Test Duration(TF—T,): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 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 recommendedfolloiv-up for failed tests) <br /> OPW BUCKETS <br /> USED PLUGS TO TEST <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the <br /> information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: V ' Date:05-15-13 <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 />