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• <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This rm is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> print uts from tests(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facili Name: SYSTEM TRANSPORT I Date of Testing: 05-15-15 <br /> Facilit i Address: 707 EAST ROTH FRENCH CAMP CALIFORNIA <br /> Facilit i Contact: SAM Phone: 209-983-8654 <br /> Date cal Agency Was Notified of Testing:04-20-15 <br /> Name 6f Local Agency Inspector(ifpresew during testing): SAN JOAQUIN CO. MICHELLE MAY 2 7 2015 <br /> 2. TESTING CONTRACTOR INFORMATION FNVIRON54P TAL <br /> Company Name: AFFORDA TEST 4162 nal Street Galt, CA 95632 (209)744-0112 F�dfbTy'iA$ 3b"� "tT <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 DIESEL 2 3 4 <br /> Numbest Stored Product, etc. <br /> Bucket Installation Type: <br /> E Direct Bury ❑Direct Bury Direct Bury Direct Bury❑ Contained in Sump El Contained in Sump ❑ Contained in El Contained in <br /> Sump Sum <br /> Bucke Diameter: 11 <br /> Bucket,Depth: 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1254 <br /> Initial Reading(Rt): 12 <br /> Test End Time(Tr): 1354 <br /> Final Reading(RF): 12 <br /> Test Duration(Tr—T,): 1 HOUR <br /> Change in Reading(RF-R,): 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: E Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> EMCO BUCKET <br /> ERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I herell y certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Techn cian's Signature: '�' Date:05-15-15 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However, local requirements <br /> may a more stringent. <br />