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NNW, <br /> 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: BJJ TRUCKING Date of Testing: 5-2-12 <br /> Facility Address: 2431 E MARIPOSA RD STOCKTON CA <br /> Facility Contact: GAYLEN Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): STACEY <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: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> -- <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: l 16 <br /> moult— <br /> Identify Spill Bucket(By Tank 1 DSL EAST 2 DSL VEST 3 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ElContained in ElContained in <br /> [IContained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: I 1 I 1 <br /> UReading(RF): <br /> pth: 13 13 <br /> between applying <br /> ater and start of test: <br /> Time(Tt): 1 2 <br /> ding(Ri): 12 12 <br /> Time(TF): 2 2 <br /> ding(RF): 12 12 <br /> Test Duration(TF—Tt): 1HR IHR <br /> Change in Reading(RF-Rt): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> Criteria: <br /> Test Result: 11 ® Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 /> �� <br /> Technician's Signature: Date 5-2-12 <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 />