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• FIKED ED <br /> SEP 2 8 MCB,January 2006 <br /> Spill Bucket Testing Report Form �Tk <br /> This form is intended for use by contractors performing annual testing of UST spill cong"V' T&3 �i eLtd,Jorm and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittjbE pWMENTatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: QUICK&EASY FOOD MART I Date of Testing: 6/27/2016 <br /> Facility Address: 824 E. YOSEMITE AVE. MANTECA, CA 95336 <br /> Facility Contact: JITENDER Phone: <br /> Date Local Agency Was Notified of Testing:6/10/2016 <br /> Name of Local Agency Inspector(if present during testing): Fatinah <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: TAPE NIEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Yank 1 87 2 89 3 91 4 <br /> Number,Stored Product, etc) <br /> ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in ❑ Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 1/2 13 1/2 13 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> fest Start Time(Tj): 9:20 9:20 9:20 <br /> Initial Reading(Ri): 12 I/2 121/2 121/4 <br /> Test End Time(TF): 10:20 10:20 10:20 <br /> Final Reading(RF): 12 1/2 12 1/2 12 1/4 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass [] Fail ® Pass ❑Fail N Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-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 Date: 6-27-16 <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 />