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■ <br />11� ' • • 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 />I- FACH.TTV INFORMATION <br />Facility Name: ORLANDOS MARKET Date of Testing: 7/12/16 <br />Facility Address: 18754 LINDEN RD / HWY 26 — �. <br />Facility Contact: SAMMY Phone: <br />Date Local Agency Was Notified of Testing :6/27/16 JUL 2 S �' <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician: ®Ed Steams ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5250492 -UT 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. gPTT.i. RTiCKRT TFRTlrNR INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />El Direct Bury <br />® Contained in Sump <br />El Direct Bury <br />® Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sum <br />E] Direct Bury <br />❑Contained in <br />Sum <br />Bucket Diameter: <br />1 I <br />11 <br />11 <br />Bucket Depth: <br />12 <br />12 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />__ <br />___ <br />Test Start Time (Ti): <br />845 <br />845 <br />845 <br />Initial Reading (Ri): <br />11 1/2 <br />11 <br />13 <br />Test End Time (TF): <br />945 <br />945 <br />945 <br />Final Reading (RF): <br />11 1/2 <br />11 <br />13 <br />Test Duration (TF — Ti): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF -Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® Pass , ❑ Fail <br />I ® Pass ❑ Fail <br />1 ® Pass ❑ Fail <br />❑ 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:) Date:7/12/16 <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 />