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+� s <br /> 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 /> 1.FACILITY INFORMATION <br /> Facility Name: GEORGE'S MINI MART I 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 416 2"a Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Zane A.Nimmo N David A.Winkler ❑ Felix G.Ramirez Ed Stearns <br /> 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 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 /> N Direct Bury N Direct Bury ®Direct Bury N Direct Bury <br /> Bucket Installation Type: El Contained in ❑ Contained in <br /> El in Sump ElContained in Sump SumpSum <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(Tj): 845 845 845 845 <br /> Initial Reading(Rj): 13 12 13 13 <br /> Test End Time(TF): 945 945 945 945 <br /> Final Reading(RF): 1 13 12 13 13 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rt): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: __:.N Pass ❑ Fail N Pass ❑Fail N Pass ❑Fail N.Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended fallow-up for ffell 117% <br /> MAR 2 5 2016 <br /> ENVIRONMEM <br /> L <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING HEALTH I_TI=P1�RMEW <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements.ei <br /> Technician's Signature V 6- 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 />