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n <br />SWRCB, �r}p�-}{,?,()06 <br />Spill Bucket Testing Report Form 8 L� I� <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. Tht�Rr�,�cl <br />ge(WEW <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the loccA& �t fKHENT <br />1. FACILITY INFORMATION <br />Facility Name: MCM14 AMPM Date of Testing: I-12-16 <br />Facility Address: 130 S WILSON WAY STOCKTON CA <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing :12-29-15 <br />Name of Local .Agency Inspector (ifpresent during leaving): ARTS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2" 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: h20 and tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (13i lank <br />\umber. Stored Product, etc.) <br />1 871 <br />2 872 <br />3 91 <br />4 <br />Bucket Installation Type: <br />F1 Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />Direct Bury <br />® Contained in <br />Sum <br />E] Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />1 1 <br />Bucket Depth: <br />14.50 <br />14.50 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />12 <br />12 <br />12 <br />Initial Reading (Rj): <br />13 <br />13 <br />13 <br />Test End Time (TF): <br />1 <br />1 <br />1 <br />Final Reading (RF): <br />13 <br />13 <br />13 <br />Test Duration (TF — TI): <br />IRR <br />1 HR <br />IHR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />I ® 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 for failed tests) <br />OPW <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: v ) <br />Date 1-12-I6 <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 />