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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(if applicable), 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 Date of Testing: 4/13/2017 <br /> Facility Address: 24323 N. HWY 99 ACAMPO, CA 95220 I r <br /> Facility Contact: SINGH Phone: <br /> Date Local Agency Was Notified of Testing:3/27/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): CESAR AF, 6 Z017 <br /> 2. TESTING CONTRACTOR INFORMATIO <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)7 Fax: 44-0116 <br /> Technician Conducting Test: ❑Ed Stearns ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 8184188 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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ® Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: <br /> Contained in Contained in <br /> ElContained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 12 1/4 13 1/2 14 1/8 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 0945 0945 0945 0945 <br /> Initial Reading(Ri): 11 1/4 12 1/2 13 1/8 11 <br /> Test End Time(TF): 1045 1045 1045 1045 <br /> Final Reading(RF): 11 1/4 12 1/2 13 1/8 11 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Z Pass ❑Fail ® Pass ❑ Fail 0 Pass ❑ Fail ® Pass ❑ Fail .i <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: 4-13-17 <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 />