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RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form AFR 2017 <br /> This form is intended for use by contractors performing annual testing of UST spill containment �y� t orm and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal tP#K*f,r�' ' �ency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: WATERLOO FOOD MART SHELL Date of Testing: 4-10-17 <br /> Facility Address: 4315 E WATERLOO RD STOCKTON CA 95215 <br /> Facility Contact: RUPI Phone: 931-3674 <br /> Date Local Agency Was Notified of Testing:2-27-17 <br /> Name of local Agency Inspector(ifpresent during testing: VICKI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2❑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 /> 8184188 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 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(i3i�lank 1 87 2 91 3 4 <br /> \umber, Stored Product, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 19 19 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1015 908 <br /> Initial Reading(Ri): 18 18 <br /> Test End Time(TF): 1115 1008 <br /> Final Reading(RF): 18 18 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or 1)16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ l'ail I ® Pass [:]Fail ❑ ❑ Fail ❑ Pass [] Fail <br /> Com ments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> onw w flanners <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-6—i Date 4-10-17 <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 />