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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisfori i is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printout from tests(f applicable), should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SYSTEM TRANSPORT I Date of Testing: 5-23-20014 <br /> Facility Address: 707 EAST ROTH FRENCH CAMP CALIFORNIA <br /> Facility Contact: SAM I Phone: 209-983-8654 <br /> Date Loc I Agency Was Notified of Testing A-16-14 <br /> Name of 1-ocal Agency Inspector(fpresent during testing): SAN JOAQUIN CO.THUY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technicia Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler ® Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credenti s': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Mett od Used: ®Hydrostatic ❑ vacuum ❑ Other <br /> Test Equi ment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify S Al Bucket(By Tank 1 DIESEL 2 3 4 <br /> Number, Stored Product, etc.) <br /> Direct ❑ Direct Bury El Direct Bury <br /> Bucket Installation Type: ® Bury El Bury ❑ Contained in E] Contained in <br /> ❑Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 120 <br /> Initial Reading(111): 12 <br /> Test End Time(TF): 220 <br /> Final Reading(RF): 12 <br /> Test Duration(TF—Tj): 1 HOUR <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass [:]Fail El Pass [:] Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> EMCO BUCKET <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 /> Te;hnician's Signature: Date: 5-23-2014 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local <br /> requirements may be more stringent. <br />