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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended far 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. FACILITY INFORMATION 2 <br /> Facility Name: SAVE ON GAS Date 4-18-16 <br /> Facility Address: 420 WEST YOSEMITE MANTECA CALIFORNIA <br /> Facility Contact: I Phone: MAY 112016 <br /> Date Local Agency Was Notified of Testing:3-29-16 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO.-ELEN <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 N David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number,Stored Product, etc. <br /> El Direct Bury El Direct Bury <br /> N Direct Bury N Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> El in Sump El in Sump Sump Sum <br /> Bucket Diameter: 11 I 1 <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(Ri): 13 13.50 <br /> Test End Time(TF): 219 219 <br /> Final Reading(RF): 13 13.50 <br /> Test Duration(TF—Tt): 1 HOUR I HOUR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: N Pass ❑FailN Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended folloiv-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informati1on contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Y""` <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 />