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�- 1 D <br /> S E P 17 N6CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> ENVIRONMENTAL <br /> Thisform is intended for use by contractors performing annual testing of UST spill contai++�ps qtfy ff{vnts YFop��letedfarm and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for subYnittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: PACIFIC SERVICE STATION I Date of Testing: 8/28/2018 <br /> Facility Address: 6131 PACIFIC AVENUE STOCKTON,CA 95207 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:8/27/2018 <br /> Name of Local Agency Inspector(ifpresent during testing): STACY R <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Steams ® 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, H2O Equipment Resolution: 1/16" <br /> identify Spill Bucket(By Tank 1 91 2 3 87 4 DIESEL <br /> Number, Stared Product, etc. <br /> ®Direct Bury El Direct B ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 14 1/2 14 I/4 13 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1055 1305 1055 <br /> Initial Reading(R,): 13 1/2 13 1/4 12 1/2 <br /> Test End Time(TF): 1 155 1405 1155 <br /> Final Reading(RF): 13 I/2 13 1/4 12 1/2 <br /> Test Duration(TF—Tt): H O U R <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> 'Test Result: ® Pass ❑Fail ❑ Pass ❑ Fail Z Pass ❑Fail ®. Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up far failed tests) <br /> ALL MEASURED 5 GALLONS <br /> HAD TO REPLACE 87 FILL ADAPTER AND RETEST 87 SPILL BUCKET <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: 8/28/2018 <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 />