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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Date of Testing: AUGUST 6,2009 <br /> Facility Name: MARIGOLD SHELL <br /> Facility Address: 6131 PACIFIC AVE STOCKTON CALIFORNIA 95207 <br /> Facility Contact: TRAN Phone: 209-952-4862 <br /> Date Local Agency Was Notified of Testing:7/10/09 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO GARETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"� 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 H2O I 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 El Bury <br /> ® Direct Bury ® Direct Bury El Contained in E]Contained in <br /> Bucket Installation Type: F-1 Contained in Sump ❑Contained in SumpSum Sum <br /> Bucket Diameter: 1 l 11 I I <br /> Bucket Depth: 12 11 11 1/2 <br /> Wait time between applying - - <br /> vacuum/water and start of test: <br /> Test Start Time(T,): <br /> 830 830 830 <br /> Initial Reading(R,): <br /> 11 10 10 <br /> Test End Time(TF): 930 930 930 <br /> Final Reading(RF): I 1 10 10 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 _ _ 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass El Fail El Pass E] Fail <br /> Comments — (include information on repairs made prior to testing, and recommended.follow-up for failed tests) <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: <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 />