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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 IDate of <br /> Facility Address: 18662 N.HWY 88 LOCKEFORD, CA 95237 <br /> Facility Contact: Rupi Padda Phone: <br /> Date Local Agency Was Notified of Testing:2-27-17 APR 1 0 2017 <br /> Name of Local Agency Inspector(ifpresent during testing): AARON <br /> 2. TESTING CONTRACTOR INFORMATIOrENVIRONMENTAL HEALTH <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-01ARA` 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: 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: ®Direct Bury ®Direct Bury ®Direct Bury ®Direct Bury <br /> yp ❑Contained in Sump El Contained in Sump ElContained in ElContained in <br /> 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(Tj): 12 12 12 12 <br /> Initial Reading(R,): 13 12 13 13 <br /> Test End Time(TF): 1 1 1 I <br /> Final Reading(RF): 13 12 13 13 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Ri): 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 recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby <br /> ,�certify that Jalll the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature Date_3-30-17 <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 />