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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SJRTD I Date of Testing: 6-22-2012 <br /> Facility Address: 1533 E LINDSAY RD STOCKTON CA <br /> Facility Contact: DOUG Phone: <br /> Date Local Agency Was Notified of Testing:5-8-12 <br /> Name of Local Agency Inspector(fpresent during testing): JEFF <br /> 2.TESTING CONTRACTOR INFORMATION n ;. <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: H2O&TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(lay Tank 1 DSL 1 2 DSI-2 3 DSL 3 4 DSL 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury Direct Bury Z Direct Bury' <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> El Contained in Sump El in Sump Sump Sum <br /> Bucket Diameter: I 1 11 11 11 <br /> Bucket Depth: 13 13.50 12 13 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 9 9 9 9 <br /> Initial Reading(Ri): 12 13 11 12 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(RF): 12 13 11 12 <br /> Test Duration(TF—Tt): I HR I HR 1 HR IHR <br /> Change in Reading(RF-R,): 0 0 O 0 <br /> Pass/Fail Threshold or 1/I6 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: Z Pass '❑ Fail ® Pass ❑ Fail ® ',Pass D Fail Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommendedfollow-upforfalled 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 /> I{ <br /> Technician's Signature: V z� '-' Date 6-22-12 <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 />