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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 (f applicable), should beprovided to the facility owner/operator for submittal to the local regulatory agency. <br />I Ti A!'n TTV TIVFf1RMAT1nN <br />Facility Name: ERNIE GENERAL STORE _ Date of Testing: 01-13-14 <br />Facility Address: 4407 WATERLOO RD STOCKTON CA <br />Facility Contact: ERNIE Phone: <br />Date Local Agency Was Notified of Testing :1-3-14 <br />Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO GARETT <br />TESTING <br />Company Name: AFFORDA TEST 4162 nd 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 Q <br />3 SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / <br />H2O <br />Equipment Resolution: <br />1/16 <br />Identify Spill Bucket (By Tank <br />1 87 <br />2 91 <br />3 DIESEL <br />4 <br />Number, Stored Product, etc. <br />® Direct Bury <br />Direct Bury <br />®Duect Bury <br />®Direct Bury <br />❑ Contained in <br />❑ Contained in <br />Bucket Installation Type: <br />❑Contained in Sump <br />❑Contained in Sump <br />Sum <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />935 <br />935 <br />935 <br />Initial Reading (Ri): <br />12 1/4 <br />12 1/4 <br />121/4 <br />Test End Time (TF): <br />1035 <br />1035 <br />1035 <br />Final Reading (RF): <br />12 1/4 <br />12 1/4 <br />12 1/4 <br />Test Duration (TF — Tj): <br />1 HOUR <br />1 HOUR <br />I HOUR <br />Change in Reading (RF -Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />TestResolt: <br />® Pass; ❑ Fail <br />® Pass ❑ Fall <br />® Pass ❑'Fail <br />❑, Pass ❑Fait <br />Comments — (include information on repairs made prior to testing, and recommendedfollow-up /urjuiteu te.,t.,i <br />OPW 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: <br />Date:01-13-14 <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 />