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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: JSKS MAIN ST ARCO I Date of Testing: 3/12/18 <br /> Facility Address: 1100 S MAINST MANTECA,CA 95337 <br /> Facility Contact: JESSE Phone: <br /> Date Local Agency Was Notified of Testing:2/27/18 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,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 /> 8883080-UT 8883064-UT 8883059-UT 8883072-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 MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank P7 2 87-S 3 89 491 <br /> Number, Stored Product, etc. <br /> E] Direct Bury E] Direct Bury <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ® Contained in ® Contained in <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1300 1300 1300 1300 <br /> Initial Reading(RI): 12 12 12 12 <br /> Test End Time(TF): 1400 1400 1400 1400 <br /> Final Reading(RF): 12 12 12 12 <br /> Test Duration(TF—Tj): IHR 1 HR 1 HR IHR <br /> Change in Reading(RF-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ®Pass ❑Fail ® Pass ❑Fail 1 ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed 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 rt' Date:3/12/18 <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 />