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CLEC ® 3 201'.%SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill c %%pletedform and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for su mittWtotcalregulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: FOODMART GAS Date of Testing: 9-28-15 <br /> Facility Address: 2185 E FREMONT STOCKTON CA <br /> Facility Contact: Kash Phone: 547-7100 <br /> Date Local Agency Was Notified of Testing:9-10-15 <br /> Name of Local Agency Inspector(f present during testing): stACY <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: ❑ 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 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(13v Tank 1 87 2 91 3 DSL 4 <br /> Xunrber, Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury <br /> ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 14.50 11.50 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tr): 10 10 10 <br /> Initial Reading(Rr): 11 14 11 <br /> Test End Time(TF): 11 14 11 <br /> Final Reading(RF): 11 10 11 <br /> Test Duration(TF—TI): IHR 1 HR IHR <br /> Change in Reading(RF-Rt): 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 /> PT ALL PASSED <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: �1 --� Date 9-28-15 <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 />