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Spill Bucket Testing Report Form NOV 05 2015 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. Thec 1 t d <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the EWMIN AL <br /> 1. FACILITY INFORMATION NFoIT�'^�onrn�e�xrr <br /> Facility Name: NATIONAL PETROLEUM Date of Testing: 05-21-15 <br /> Facility Address: 713 N EL DORADO ST STOCKTON CA <br /> Facility Contact: ARSHID Phone: 209-465-5222 <br /> Date Local Agency Was Notified of Testing:04-25-14 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in Sump ®Contained in Sump ®Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 I I 11 <br /> 'Bucket Depth: 13 13 13 <br /> ,Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1305 1305 1305 <br /> Initial Reading(Rj): 13 13 13 <br /> Test End Time(TF): 1405 1405 1405 <br /> Final Reading(RF): 13 13 13 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR <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 /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <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:05-21-15 <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 />