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• <br /> 4RECENED <br /> OCT MRIJanuary 2006 <br /> Spill Bucket Testing Report Form <br /> c9 NTAL HEALTH <br /> This form is intendedfor use by contractors performing annual testing of UST spill contain t e:ire form and <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: SUPER STORE I Date of Testing: 10-07-16 <br /> Facility Address: 16888 MCKINLEY RD LATHROP CA <br /> Facility Contact: Scott Sommerfeld Phone: 209-858-3384 <br /> Date Local Agency Was Notified of Testing:09-24-16 <br /> Name of Local Agency inspector(if present during testing): SAN JOAQUIN CO VICKIE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211 Street Galt,CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': 0 ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: TAPE 11-120 Equipment Resolution: 1116 <br /> Identify Spill Bucket (By Tank I DIE 1 2 DIE 2 3 WASTE OIL 4 NEW OIL <br /> Number,Stored Product, etc.) <br /> ❑ <br /> ® Direct Bury ®Direct Bury Direct Bury El Direct Bury <br /> Bucket Installation Type: M Contained in ® Contained in <br /> ❑ Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: I l 1 1 l 1 l l <br /> Bucket Depth: 14 14 14 14 <br /> Wait time between applying - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1200 1200 1200 1200 <br /> Initial Reading(Rj): 13 13 13 13 <br /> Test End Time(TF): 1300 1300 1300 1300 <br /> Final Reading(RF): 12 112 13 13 13 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR I HOUR l HOUR <br /> Change in Reading(RF-Rj): 112 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ❑ Pass ®Fail ® Pass []Fail Z Pass ❑ Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recotrunended follow-up far,failed lents) <br /> QPW BUCKETS <br /> ALL BUCKETS HOLD AT LEAST 5 GALLONS. <br /> TANK 1 DIESEL BUCKET-HAS SMALL HOLE ON THE OUTSIDE OF <br /> BUCKET, ITE WELL HAVE REPAIRED AND RETESTED <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:10-07-16 <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 />