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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I FAf TT.TTV TNFTIRMATT0N <br />Facility Name: WIGHT COLLINS AM/PM Date of Testing: 1/21/10 <br />Facility Address: 130 S. WILSON WAY STOCKTON, CA 95205 <br />Facility Contact: LAWRENCE Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): JEFF WONG <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />2 CDTT T RTTrWFT TFCTTNr_ TNFORMATT()N <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 T1 <br />2 87 T2 SLAVE <br />3 91 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />® Contained in <br />SUMP <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <br />I I <br />1 I <br />Bucket Depth: <br />14 <br />13 3/4 <br />143/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />-- <br />-- <br />Test Start Time (Ti): <br />1 140 <br />1140 <br />1140 <br />Initial Reading (Rj): <br />14 <br />13 1/8 <br />14 1/8 <br />Test End Time (TF): <br />1240 <br />1240 <br />1240 <br />Final Reading (RF): <br />14 <br />13 1/8 <br />14 1/8 <br />Test Duration (TF — Tj): <br />hr <br />hr <br />hr <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing and recommended follow-up jor jailed 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 />Technician's Signature: Date: 1-20-10 <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 />