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' • SWRCB.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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pacific Service Station I Date of Testi 08-31-17 <br /> Facility Address: 6131 PACIFIC AVE STOCKTON CALIFORNIA 95207 <br /> Facility Contact: DAVE Phone: 209-475-9842 <br /> Date Local Agency Was Notified of Testing:07-20-17 C;F P ia ?M-1 <br /> t <br /> Name of Local Agency Inspector(fpresent during testing/: SAN JOAQUIN CO ALAINA <br /> 2. TESTING CONTRACTOR INFORMATION L' <br /> r <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 DIE 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury ® Direct Bury r-1DirectBury <br /> Bucket Installation Type: El Contained in El Contained in <br /> F1 Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: I 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(Ti): 930 930 930 <br /> Initial Reading(Ri): I I 11 I l <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 11 11 11 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(R,:-R,): 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 /> 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:8-31-17 <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 />