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r • S WRCB,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(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION — <br /> Facility Name: SAVE ON GAS Date 4-18-16 <br /> Facility Address: 420 WEST YOSEMITE MANTECA CALIFORNIA <br /> Facility Contact: Phone: Y 1 6 <br /> Date Local Agency Was Notified of Testing:3-29-16 <br /> Name of Local Agency Inspector(tfpresent during testing): SAN JOAQUIN CO. -ELENA ,6w.�. <br /> 2. TESTING CONTRACTOR INFORMATION <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: "PAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury E] Contained in <br /> ❑ Direct Bury ❑ Direct Bury <br /> E]Contained in Sump E] Contained in Sump ❑Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 119 119 <br /> Initial Reading(Rj): 13 13.50 <br /> Test End Time(TF): 219 219 <br /> Final Reading(RF): 13 13.50 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass <br /> ❑ Fail <br /> Comments— (include information on repairs made prior to testing and recommended follow,-up for failed 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 /> Technician's Signature: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. <br /> However, local requirements may be more stringent. <br />