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EDMAR VW019anuary 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended far use by contractors performing annual testing of UST spill containment structures The;Fogtj{(ete�lorYY and <br /> rintouts om tests i a licable should be provided to thefacility ownerlo rator or submittal to the local regulatory agency. <br /> P fr ff PP � ), P f tJ' Pe f 8u rJ' 8 Y <br /> 1. FACILITY INFORMATION <br /> Facility Name: GEORGE'S MINI MART Date of Testing: 3-8-2016 <br /> Facility Address: 18662 N. HWY 88 LOCKEFORD, CA 95237 <br /> Facility Contact: Rupi Padda Phone: <br /> Date Local Agency Was Notified of Testing:3-2-16 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez Ed Stearns <br /> 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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury ®Direct Bury Direct Bury Direct Bury <br /> El Contained in Sump ❑ E]Contained in El Contained inContained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 14 13 13 1/2 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 845 845 845 845 <br /> Initial Reading(R,): 13 12 13 13 <br /> Test End Time(TF): 945 945 945 945 <br /> Final Reading(RF): 13 12 13 13 <br /> Test Duration(TF—T,): HR HR HR HR <br /> Change in Reading(RF-R,): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-upforfailed 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 /> ei <br /> Technician's Signature V�—' Date: 3-8-2016 <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 />