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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (ifopplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />JAMAR SVC Date of Testing: 05-19-15 <br />Facility Name. <br />Facility Address: 4075 EAST AMIN STREET STOCKTON CALIFORNIA <br />Test Equipment Used: TAPE H2O Equipment Resolution: 1/I6 <br />Facility Contact: JASON Phone: 209-462-4685 16M 1 V 16 <br />Date Local Agency Was Notified of Testing: JUN 10 20i5 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO ELANA <br />2. TESTING CONTRACTOR INFORMATION ENVIRONMENI <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 />x enrr t RITrTZRT TF.CT1Nf_ INFORMATION <br />Test Method Used: ® Hydrostaticu Y ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O Equipment Resolution: 1/I6 <br />Identify Spill Bucket (By Tank <br />1 87 <br />2 91 <br />3 <br />4 <br />Number, Stored Product, etc. <br />El Direct Bury <br />❑ Direct Bury <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />❑ Contained in <br />E] Contained in <br />SumpSum <br />Bucket Diameter: <br />I 1 <br />11 <br />Bucket Depth: <br />14 <br />13 <br />Wait time between applying <br />_ <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />904 <br />904 <br />Initial Reading (Ri): <br />13 <br />12 <br />Test End Time (TF): <br />1004 <br />1004 <br />Final Reading (RF): <br />13 <br />12 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF- Rt): <br />0 <br />0 <br />Pass/Fail Threshold or <br />0 <br />0 <br />0 <br />0 <br />Criteria: <br />Test Result: <br />I ®Pass ❑ Fail <br />®. Pass ❑ Fail <br />I ❑ Pass L] Fail <br />❑ Pass ❑ Fail <br />Comments (include information on repairs made prior to testing and recommendedfollow-upforfatled tests) <br />(DPW BUKCETS - <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 <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 />L) <br />