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IED <br /> j,jN, 0 1MI" <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form ENVIRONMENTAL <br /> A TH nFpaRTMENT <br /> This form is intended for use by contractors performing annual testing of UST spill contains uctures. The completed f m 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 /> Facility Name: PIOUS PETROLEUM I Date of Testing: 5/1/2018 <br /> Facility Address: 713 N. ELDORADO STREET STOCKTON , CA 95603 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during testing): STACY R. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-01 16 <br /> Technician Conducting Test: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ram ez <br /> 8883080—UT 8883064-UT 8883059-UT 8883072-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 dank 1 87 2 3 91 4 DIESEL <br /> Number,Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in ®Contained in <br /> ® Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 1 1 11 11 <br /> Bucket Depth: 15 1/2 13 1/2 17 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0945 0945 0945 <br /> Initial Reading(Rt): 13 1/4 12 3/4 14 1/2 <br /> Test End Time(TF): 1045 1045 1045 <br /> Final Reading(RF): 13 1/4 11 - 14 1/2 <br /> Test Duration(TF—Tj): HOUR HR HR <br /> Change in Reading(RF-Rj): 0 0 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 /> 91 SPILL BUCKET LEAKED INTO FILL SUMP. FAIL Elite IV to repair&retest. <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: 5/1/2018 �I <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 />