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t i <br /> • SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisform is intended for use by contractors performing annual testing of UST spill containment structures. The completed.form and <br /> printouts f•om tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: STOCKTON USD Date of Testing: 05-07-10 <br /> Facility Address: 1932 EL PINA DR ----- - <br /> Facility Contact: BUTCH Phone: 209-933-7045 <br /> Date Local Agency Was Notified of Testing:04-20-10 ---- <br /> Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO. <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AF'FORDA TEST 4162 A Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: <br /> El Lyle D. Nimmo i❑ Zane A.Nimmo F-1DavidA. 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 E] Other <br /> ® <br /> Equipment Resolution: 1/16 <br /> Test Equipment Used: TAPE/H2O <br /> Identify Spill Bucket(By Tank 1 87 <br /> 2 DIE 3 4 <br /> Number, Storedfroduct, etc.) ❑ Direct Bury ❑ Direct Bury <br /> ❑ Direct Bury ❑ Direct Bury ❑ Contained in ❑Contained in <br /> [Bucket Installation Type: ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: I 1 I 1 <br /> Bucket Depth: 15 15 <br /> Wait time between applying _ - — <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1305 1305 _ --- <br /> -- 14 137/ - - <br /> Initial Reading(R1): _ <br /> Test End Time(TF): 1405 1405 --- <br /> ' --- <br /> Final Reading(RF): 1 14 137/8 <br /> JFChange <br /> est Duration(TF-TI): <br /> 1 HOUR 1 HOUR in Reading(RF-R,): <br /> Pass/Fail Threshold or <br /> [Criteria: <br /> Test Result: ® Pass ❑ Fail I ® Pass ❑ Fail pass Fail ❑ Pass El Fail <br /> Comments- (i,7clurle it f rrmatian 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 /> Date:5-7-10 <br /> Technician's Signature: <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. I-lowever, local requirements <br /> may be more stringent. <br />