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f 9 ,! <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ALPHA FAST GAS I Date of Testing: 04-25-13 <br /> Facility Address: 2348 WATERLOO RD STOCKTON CA <br /> Facility Contact: JIMMY Phone: 408-204-3812 <br /> Date Local Agency Was Notified of Testing:4-19-13 <br /> Name of Local Agency Inspector(i(present during testing): JEFF WONG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nirnmo ❑ Zane A.Nimmo ❑ David A. Winkler Z Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': Z ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> Z Direct Bury Z Direct Bury Z Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Contained in ❑Contained in <br /> L] Contained in Sump E] Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 1 I <br /> Bucket Depth: 13 13 15 112 <br /> Wait time between applying _ _ - <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1330 1330 1330 <br /> Initial Reading(R,): 12 12 14 <br /> Test End Time(TF): 1430 1430 1430 <br /> Final Reading(RF): 12 12 14 <br /> Test Duration(TF o Ti): I HOUR I HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: [A Pass ❑ Fail H Pass ❑ Fail Z Pass ❑ Fail ❑ Pass [] Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> QPW BUCKETS <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: Date:04-25-13 <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 />