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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: MCM14 AMPM I Date of Testing: 1.19-2018 <br /> Facility Address: 130 S WILSON WAY STOCKTON CA 95205 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): AARON <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Gait,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8184188-UT 8211269-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 Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 871 2 872 3 91 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in ❑Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: I I 1 1 11 <br /> Bucket Depth: 14.50 14.50 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1030 1030 1030 <br /> Initial Reading(RI): 13 13 13 <br /> Test End Time(TF): 1130 1130 1130 <br /> Final Reading(RF): 13 13 13 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1-16 1/16 <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 /> 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: Date I-19-2018 <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 />