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Spill Bucket Testing Report Form SWRCB,January 2006 <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.FACILrff INFORMATION <br /> Facility Name: WOODBRIDGE AMPM Date of Testing: 4-11-2016 <br /> Facility Address: 18806 LOWER SAC WOODBRIDGE CA <br /> Facility Contact: JAS I Phone: <br /> Date Local Agency Was Notified of Testing:3-29-16 <br /> Name of Local Agency Inspector(if present 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: Rl Hydrostatic ❑ Vacuum D 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 q <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bur Direct Bury Direct Bury <br /> ®Contained in Sump ®Contained in Sump ®Contained in ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 16 16 <br /> 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): 10301030 1030 <br /> Final Reading(RF): 15.50 15 14.50 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-Ri): 0 p <br /> 0 <br /> Pass/Fail Threshold or 1/16 <br /> Criteria: 1/16 1/16 <br /> Test Result: jPsss ❑ Fail Pass ❑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 /> 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: v &-- 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 />