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RECEIVED <br /> • SWRCB,January 2006 <br /> Spill Bucket Testing Report Fob 13 2017 <br /> This form is intended for use by contractors performing annual testing of UST spill containm t r h�Tmpleted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/o�d c regulatory agency. <br /> 1. FACILITY INFORMATION DEPARTMENT <br /> Facility Name: KWIK SERV I Date of Testing: 6/26/20J7 <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 2"d Street Galt,CA 95632 (209)744-0112 Far: (209)744-0116 <br /> Technician Conducting Test: ❑ Ed Steams E Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> E Direct Bury E Direct Bury E Direct Bury El Direct Bury <br /> Bucket Installation Type: ElContained in ❑ Contained in <br /> El Contained in Sump ElContained in Sump Sump Sum <br /> Bucket Diameter: I I 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): 12 1/2 121/2 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—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E Pass ❑ Fail E Pass ❑Fail E 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 />