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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: UNITED GAS Date of Testing: 2-2-2018 <br /> Facility Address: 3440 E MAIN ST. STOCKTON CA 95205 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:1131/18 <br /> Name of Local Agency Inspector(if present during testing): JOHN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Al♦FORDA TEST 416 2°a 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-UT 8211269-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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Mnh 1 87 2 91 3 89 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> El Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 1 I 11 1 I <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying _ <br /> vacuum//water and start of test: - <br /> Test Start Time(Ti): 11 11 11 <br /> Initial Reading(RI): 12 12 12 1/2 <br /> Test End Time(Tr:): 12 12 12 <br /> Final Reading(RF): 12 12 12 112 <br /> Test Duration(Te—Ti): 1HR IRR 1HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1116 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail ® Pass . ❑Fail ❑ Pass ❑ Fail <br /> Comments—(inchide information on repairs made prior to testing, and recommended follotiv-sip for failed tests) <br /> OPw <br /> CERTIFICA'T'ION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby Certify that all the information Contained in fills report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: v Date 2-2-18 <br /> r 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 />