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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 /> Facility Name: NATIONAL PETROLEUM Date of Testing: 5/16/2016 <br /> Facility Address: 713 N. EL DORADO ST. STOCKTON, CA 95202 <br /> Facility Contact: Phone: t.- `-- <br /> Date Local Agency Was Notified of Testing:4/25/2016 jUN 17 2016 <br /> [Lame Lal Agency Inspector(rfpresent during testing): VICKIE <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: ❑ 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury El Direct Bury <br /> ti Bucket Installation Type: ®Contained in ®Contained in <br /> ® Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 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): 0937 0937 0937 <br /> Initial Reading(111): 12 3/4 12 5/8 15 <br /> Test End Time(TF): 1037 1037 1037 <br /> Final Reading(RF): 12 3/4 12 5/8 15 <br /> Test Duration(TF–Ti): HR HR 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 I ® Pass ❑ Fail I ® Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended fbllow-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:-5-16-16 <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 />