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I -6� '✓, <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form APR 15 2016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment strtu�.$1( tedjorm and <br /> printouts from tests(ifopplicable),should be provided to the facility owner/operator for submrttQ�(ap7�iG 'kT:r."kg+ilatopletedf cy. <br /> :r�T.tJ 11CDu+rTiv <br /> 1.FACILITY INFORMATION <br /> Facility Name: WOODBRIDGE AMPM I Date of Testing: 4-11-2016 <br /> Facility Address: 18806 LOWER SAC WOODBRIDGE CA <br /> Facility Contact: JAS Phone: <br /> Date Local Agency Was Notified of Testing:3-29-16 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS <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 El Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> El El Direct Bury ❑Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ®Contained in ❑Contained in <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: I 1 11 I1 <br /> Bucket Depth: 16 16 16 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 930 930 930 <br /> Initial Reading(RI): 15.50 15 14.50 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 15.50 15 14.50 <br /> Test Duration(TF—Tt): 1HR IHR IHR <br /> Change in Reading(RF-Rt): 1 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass El Fail ® Pass El Fail ® Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: T` — Date 4-11-2016 <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 />