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i 11 <br /> AUG 0 3 LU I t CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill conttaaiimmn TM-(cl AeT*rm and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator fo ��M�7n 41 e"tory agency. <br /> 1.FACELITY INFORMATION ir' 1 <br /> Facility Name: MY MINI MART I Date of Testing: 06-29-17 <br /> Facility Address: 1756 NORTH WILSON WAY STOCKTON CA 95205 <br /> Facility Contact: SINGH Phone: 775-421-9978 <br /> Date Local Agency Was Notified of Testing:05-18-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO GARRET <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TESV 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Steams ❑ Zane A.Nimmo ❑ David A.Winkler N Felix G.Ramirez <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> 4 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 _ <br /> Number, Stored Product, etc. <br /> N Direct Bury N Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 1300 1300 <br /> Initial Reading(Rt): 13 1/2 13 <br /> Test End Time(TF): 1400 1400 <br /> Final Reading(RF): 13 1/2 13 <br /> Test Duration(TF-Ti): I HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑ Fail N Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail, <br /> Comments- (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <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:06-29-17 <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 />