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F . y • 0 RE SED <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of USTspi/l containment structures. The A411; Wand <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION ENVIRONMENTAL HEALTH <br /> Facility Name: SUPER STORE I Date of Testing: DEPARTMENT <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(fpresent during testing): SAN JOAQUIN CO VICKIE <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 20d 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': 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 DIE 1 2 DIE 2 3 WASTE OIL 4 NEW OIL <br /> Number, Stored Product, etc. <br /> ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: E Direct Bury E Direct Bury ®Contained in E Contained in <br /> ❑Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 1 I 11 <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(R,): 13 13 13 13 <br /> Test End Time(TF): 1300 1300 1300 1300 <br /> Final Reading(RF): 12 1/2 13 13 13 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR I HOUR 1 HOUR <br /> Change in Reading(RF-R,): 1/2 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ❑ Pass E Fail E Pass ❑Fail E Pass ❑ Fail ff Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS HOLD AT LEAST 5 GALLONS. <br /> TANK I DIESEL BUCKET HAS SMALL HOLE ON THE OUTSIDE OF <br /> BUCKET. SITE 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 />