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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUL 0 8 2`^ <br /> This form is intended for use by contractors performing annual testing of UST spill containmenAswxetzfCThe-completed form and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submittal tot local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> F77"', <br /> FAST AND EASY Date of Testing: 06-08-16 <br /> 1399 YOSENITE AVE MANTECA CA <br /> DEEP Phone: 209-823-3460 <br /> Date Local Agency Notified of Testing:05-19-16 <br /> Name of Local Agency Inspector(if present during testing): SAN JAOQUIN CO ELANA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFF RRDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler ® Felix G.Ramirez <br /> 5249115-UT 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ® Direct Bury ®Direct Bury El Contained in ❑ Contained in <br /> d i <br /> ❑ Contained in Sump ❑ Contained Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 1 13 13 <br /> Wait time betweenapplying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 910 910 910 <br /> Initial Reading(RI): 12 12 12 <br /> Test End Time(TF): 1010 1010 1010 <br /> Final Reading(RF): 12 12 12 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or _ - <br /> Criteria <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS HOLD 5 GALLONS <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:06-08-16 <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 />