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N . *W# 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 CO TRUCKING I Date of Testing: 05-26-10 <br /> Facility Address: 2431 EAST MARIPOSA RD STOCKTON CALIFORNIA 95205 <br /> Facility Contact: Phone: 209-941-2576 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector('(present during testing): RAY VON FLUE <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 /> Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> - — <br /> Test Method Used: ® Hydrostatic ❑Vacuum El Other <br /> 'fest Equipment Used: TAPE/ H2O I Equipment Resolution: li 16 <br /> Identify Spill Bucket By Tank I DIE 2 DIE 3 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 SumpSum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tr): 1250 1250 <br /> Initial Reading(Rt): 12 12 <br /> Test End Time(TF): 1350 1350 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—Tr): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rr): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ®.Passe. ❑ Fail I ® 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 /> Technician's Signature: Date: <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 />