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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 /> printoutsfrom tests(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: JAHANT FOOD & FUEL I Date of Testing: 4/12/2018 <br /> Facility Address: 24323 N. HIGHWAY 99 ACAMPO , CA 95220 <br /> Facility Contact: SINGH Phone: <br /> Date Local Agency Was Notified of Testing:3/20/2018 <br /> Name of Local Agency Inspector('(present during testing): CESAR <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns N Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8211269—UT 8883064-UT 5263373-UT 5273934-UT <br /> Credentials: N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By lank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: N Direct Bury N Direct Bury ® Direct Bury ®Direct Bury <br /> yP ❑ Contained in Sump El Contained in Sump ❑ Contained in ElContained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 12 1/4 13 1/2 14 I/8 12 - <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0930 0930 0930 0930 <br /> Initial Reading(111): 11 1/4 12 1/2 13 1/8 11 - <br /> Test End Time(TF): 1030 1030 1030 1030 <br /> Final Reading(RF): 11 1/4 12 1/2 13 I/8 11 - <br /> Test Duration(TF—Tt): HR HR HR HR <br /> Change in Reading(RF-Rj): 1 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- -- <br /> Test Result: N Pass ❑Fail N Pass ❑ Fail N Pass ❑Fail N Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-up forfailed tests) <br /> ALL MEASURED 5 GALLONS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informationcontainedin this report is true,accurate,and in full compliance with legal requirements. <br /> n � <br /> Technician's Signature: `' Date: 4/12/2018 <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 />