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�./ SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for pl cable e by contractors <br /> should be provided to the facility owner operator for ill subm submittal to the local regulatnment structures. The letedform ory agency.and <br /> printouts from tests(if applicable),), P <br /> 1.FACILITY INFORMATION <br /> esting: 5-22-]3 <br /> Facility Name: BJJ TRUCKING <br /> Date of T <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(fpresent during testinp�: STACEY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°"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 /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 116 <br /> I6 <br /> Identify Spill Bucket(By Tank 1 DSL EAST 2 DSL WEST 3 4 <br /> Number, Stored Product, etc) <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: ® Dvect Bury ®Direct Bury ❑Contained in El 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(TO: 1 1 <br /> Initial Reading(RI): 13 13 <br /> Test End Time(TF): 2 2 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—TI): 1 HR IRR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1116 1/16 <br /> Criteria: <br /> Test Result: ® 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 /> Technician's Signature: xl ") JDate 5-22-13 <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 />