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RECEIVED <br /> 0 C T 1 1;jpVB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This farm is intended far use by contractors performing annual testing of UST spill cont"af@NMff.Wq*4hFe -ft+and <br /> printouts from tests(ifopplicable),should be provided to the facility owner/operatorfor submittatqft "MS�Wry agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: KWIK SERV Date of Testing: 6/26/2017 <br /> Facility Address: 824 E. YOSEMITE AVE.MANTECA, CA 95336 <br /> Facility Contact: MIKE Phone: <br /> Date Local Agency Was Notified of Testing:5/19/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): JOHN <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: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑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 /> Test Start Time(Ti): 0930 0930 0930 <br /> Initial Reading(Ri): 121/2 12 1/2 12 1/4 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 12 1/2 12 1/2 12 1/4 <br /> Test Duration(TF—Ti): 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 ® 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 /> 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: 6-26-17 <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 />