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0 <br />It w:A4wa;.O W' <br />SOMRCB, January 2006 <br />Spill Bucket Testing Report Form JUL 2 5 2016 <br />This form is intendedfor use by contractors performing annual testing of UST spill containment�s(r[ur�t. The cgtppletedform and <br />printoutsfrom tests (ifapplicable), should be provided to thefacility owner/operator for, suknpj(tg(((o t1,Kegplgtory agency. <br />1. FACILITY 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 <br />Name of Local Agency Inspector (ifpresent during testing): <br />i 11A U GUN 1 HAUL Vl(1N <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician: NEd Steams ❑ Lyle D. Nimmo ❑ Zane A. Nimmo <br />5250492 -UT ❑David A. Winkler ❑Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. N SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATinN <br />Test Method Used: N Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Bucket <br />(By Tank Spill <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />YP <br />El Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />®Contained in Sump <br />Direct Bury <br />❑Contained in <br />SUMP <br />Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />l2 <br />12 <br />14 <br />between applying <br />vacuum/water and start of test: <br />==start <br />-- <br />--- <br />--- <br />Test Start Time (T,): <br />845 <br />845 <br />845 <br />Initial Reading (R,): <br />11 1/2 <br />11 <br />13 <br />Test End Time (TF): <br />945 <br />945 <br />945 <br />Final Reading (RF): <br />1 1 11/2 <br />11 <br />13 <br />Test Duration (TF —T,): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF- R,): <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 />® Pass ❑ Fail <br />N Pass ❑ Fail <br />❑ Pass [-I 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:) fi( 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 />