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` y SWRCB,January 2006 V <br /> Spill Bucket Testing Report Form JUN 15 2017 <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(f applicable), should be provided to the facility owner/operator for submittal t0(F#�p M�tALTH <br /> 1.FACILITY INFORMATION DEPARTMENT <br /> Facility Name: SRH I Date of Testing: 5-22-17 <br /> Facility Address: 749 E CHARTER WAY STOCKTON CA 95206 <br /> Facility Contact: JOHNNIE Phone: 465-8979 <br /> Date Local Agency Was Notified of Testing A-27-17 <br /> Name of Local Agency Inspector(ifpresent during testing): VICKI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2od Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> _.... <br /> Identify Spill Bucket(By Tank 1 DSL 2 87 3 91 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: <br /> ® Direct Bury ®Direct Bury ® Direct Bury Lj Direct Bury <br /> ❑ Contained in ❑Contained in <br /> E]Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I 1 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1015 1015 1015 <br /> Initial Reading(RI): 12 12 113/4 <br /> Test End Time(TF): 1115 1115 1115 <br /> Final Reading(RF): 12 12 11 3/4 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/I6 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass El Fail ® 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 FLAPPERS <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 5-22-17 <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 />