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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(f 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 I Date of Testing: 06-27-17 <br /> Facility Address: 3440 E MAIN ST STOCKTON CA 950205 <br /> Facility Contact: MANPREET Phone: 925-914-0873 <br /> Date Local Agency Was Notified of Testing:05-18-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A.Nimmo ❑ David A.Winkl -Felix fps Ramirez, <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ®SWRCB Tank Tester SEP 1 4 201( <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other _ <br /> Test Equipment Used: TAPE/ 1120 F'-quipment Resolution: 1 16 <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury ® Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): 935 935 935 <br /> Initial Reading(R,): 12 12 12 <br /> Test End Time(TF): 1035 1035 1035 <br /> Final Reading(RF): 12 12 12 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Ri): --10-- _'0 0- <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ' Pass ❑ Fail ® Pass [:] Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to tesling, and recommended follow-up for jailed tests) <br /> OPW BUCKETS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: U � Date:06-27-17 <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 />