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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUN 19 2018 <br /> This form is intended for use by contractors performing annual testing of UST spill containment s t res., pleted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for subm N"e 7q'cirl� ry agency. <br /> H <br /> 1. FACILITY INFORMATION <br /> Facility Name: J & L MARKET Date of Testing: 5/30/2018 <br /> Facility Address: 8125 S. EL DORADO STREET FRENCH CAMP , CA 95231 <br /> Facility Contact: EUGENIA Phone: <br /> Date Local Agency Was Notified of Testing:4/25/2018 <br /> Name of Local Agency Inspector(f present during testing): STACY R. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez ❑ Ed Stearns <br /> #8883064 -UT #8883059-UT #8883072-UT #8883080-UT <br /> Credentials t: ®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 3 91 4 DIESEL <br /> Number,Stored Product, etc. <br /> ®Direct Bury ❑ Direct Bury ®Direct Bury ® Direct Bury <br /> Bucket Installation Type: <br /> ❑ El Contained in El Contained inContained in Sump Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 13 1/4 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 0921 0921 0921 <br /> Initial Reading(Rt): 12 7/8 12 1/4 13 <br /> Test End Time(TF): 1021 1021 1021 <br /> Final Reading(RF): 12 7/8 12 1/4 13 <br /> Test Duration(TF—TI): HOUR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Pail ❑ Pass ❑ Fail ® Pass ❑Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ALL MEASURED 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: 5/30/2018 <br /> t 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 />