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t <br /> S W RCB,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 faci4ty owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MARIGOLD SHELL I Date of Testing: 08-25-14 <br /> Facility Address: 6131 PACIFIC AVE STOCKTON CALIFORNIA 95207 <br /> Facility Contact: TRAN Phone: 209-9524862 <br /> Date Local Agency Was Notified of Testing:8-20-14 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO GARRETT <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: ❑ 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: TAPE 1120 Equipment Resolution: 1/16 <br /> ,, <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc.) <br /> Direct Bury Ll Direct Bury <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury El Sump <br /> in [j Contained in <br /> ❑ Contained in Sump <br /> El in Sump Sum Sum <br /> Bucket Diameter: 1 1 11 I 1 <br /> Bucket Depth: 12 11 11 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): 1 130 1130 1130 <br /> Initial Reading(Rj): 1 1 10 10 <br /> Test End Time(TF): 1230 1230 1230 <br /> Final Reading(RF): 11 10 10 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <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 /> a <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:_er�� Date: 8-25-14 <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 />