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pFC[7- <br /> MT, <br /> Spill Bucket Testing Report Form NOV 0 6 2W <br /> RCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill coL mninent.structures. The comp (QeJform and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator or submittal to thg-lyaal rejulatory agency. <br /> JLI r��i i Vii J <br /> 1. FACILITY INFORMATION <br /> Facility Name: 99 SHELL I Date of Testing: 8-22-17 <br /> Facility Address: 7700 MORELAND RD.STOCKTON,CA 95212 <br /> Facility Contact: ANGLE Phone: 209-957-5398 <br /> Date Local Agency Was Notified of Testing:7-24-17 <br /> Name of Local Agency Inspector(f present during testing): VICKI <br /> 2. TESTING CONTRACTOR INFORMATION <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 MEASURE, H 2 0 Equipment Resolution: 1'16" <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 2 4 <br /> Number, Stored Product, etc. <br /> El Direct Bury E] Direct Bury <br /> Bucket Installation Type: ❑ Direct Bury E:1 Direct Bury ® Contained in El Contained in <br /> ® Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 1/4 16 1/2 16 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 11 <br /> Initial Reading(RI): 13.50 15 15 <br /> Test End Time(TF): 10 10 12 <br /> Final Reading(RF): 13.50 15 15 <br /> Test Duration(TF—Tj): HOUR HOUR HOUR <br /> Change in Reading(RF-Rt): 0 0 1 0 <br /> Pass/Fail Threshold or <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 <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 /> W <br /> Technician's Signature:_._ Date: 8-22-17 <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 />