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r. <br /> 2006 <br /> Spill Bucket Testing Report Form NOV 0 4 2013 <br /> Thu 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 facilityowner/operator for submith <br /> ,AWj1bA&qW6VVptWry agency. <br /> 1.FACITY INFORMATION ENVIRONMENTAL <br /> IL <br /> Facility Name: QUICKI KLEEN I Date of Testing: 10-16-13 <br /> Facility Address: 707 E YOSEMITE AVE MANTECA CA <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:9-12-13 <br /> Name of Local Agency Inspector(fpresent during testing): ELENA <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: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 1 2 87 2 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury El Direct Bury <br /> Bucket Installation Type: <br /> [:1 Direct Bury El Direct Bury ® Contained in E] Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Stun <br /> Bucket Diameter: 11 11 I I <br /> Bucket Depth: 15 17 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 1015 1015 1015 <br /> Initial Reading(RI): 14 16 14 <br /> Test End Time(TF): 1115 Ills 1115 <br /> Final Reading(RF): 14 16 14 <br /> Test Duration(TF—TI): 1HR IHR IHR <br /> Change in Reading(RF-Rl): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail I ® Pass ❑Fail I M Pass ❑Fail ❑ Pass ❑ 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> �� <br /> Technician's Signature: vl al— aiDate 10-16-13 <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 />