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� r • r <br /> 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: Refuel Circle K Date of Testing: 5/15/2017 <br /> Facility Address: 419 S. MAIN STREET MANTECA, CA 95337 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:4/27/2017 <br /> Name of Local Agency Inspector(if present during testing): VICKIE <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: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ®Direct Bury El Direct Bury ❑Contained in El Contained in <br /> El Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 1 I 11 11 <br /> Bucket Depth: 15 15 15 1/2 <br /> Wait time between applying -- -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1000 1000 1000 <br /> Initial Reading(RI): 13 3/4 14- 13 1/4 <br /> Test End Time(TF): 1100 1100 1100 <br /> Final Reading(RF): 13 3/4 14- 13 1/4 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> L_ I <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> b <br /> .illy fli � <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full complianere"WYth-teffai requir Is.H EALTH <br /> Technician's Signature Date 5-15-17 <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 />