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�p 'DECEIVE® <br /> Spill Bucket Testing Report Form <br /> OCT 2 31V CB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment tr c l��e (jrm and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator fo IJ g aIlNy agency. <br /> 1. FACILITY INFORMATION DEPARTME T <br /> Facility Name: DELTA ARCO Date of Testing: 08-30-17 <br /> Facility Address: 440 WEST CHARTER WAY STOCKTON CA 95206 <br /> Facility Contact: MAJOR Phone: 209465-2487 <br /> Date Local Agency Was Notified of Testing:07-20-17 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO CEASER <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: ❑ Ed Stearns ❑ Zane A.Nimmo ❑ David A. Winkler ® Felix G.Ramirez <br /> 8184188 8211269 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: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ® Direct Bury ❑ Direct Bury El Direct Bury <br /> Bucket Installation Type: El Contained in <br /> ❑ Contained in Sump E] Contained in Sump El Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1000 1000 <br /> Initial Reading(Ri): 13 13 <br /> Test End Time(TF): 1100 1100 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—T,): I HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or <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 BUCKETS <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:08-30-17 <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 />