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f i SWRCB,January 2006' <br /> Spill Bucket Testing Report Form <br /> Thisfor m is intended for use by contractors performing annual testing UST spill containment sir tures. The completed.form and <br /> printouts from tests (if applicable), should be provided to the facility ow er/operator for submittal t the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SKYMART VALERO Date ofTestin 4-28-2010 <br /> Facility Address: 713 N ELDORADO STREET STOCKTO C A <br /> Facility Contact: ALI Phone: <br /> Date Local Agency Was Notified of Testing: <br /> -- <br /> Name of Local Agency Inspector(if present during testing): ARIS <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: ❑ Lyle D.Nimmo ❑ Zane A,N mmo ® David A. Winkl r ❑ Felix G. Ramirez <br /> 5249115-UT 5263322 UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTIWG INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DSL 4 1 <br /> Number, Stored Product, etc. -- <br /> ❑ Direct BuDirect Bury <br /> [:1 Direct Bury ❑ Direct Bary ® Containedin El Contained in <br /> Bucket Installation Type: ® Contained in Sump ® Contained in SumpSum Sum <br /> Bucket Diameter: 1 1 11 11 <br /> Bucket Depth: 15 14 17 <br /> Wait time between applying - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): <br /> 930 930 930 <br /> Initial Reading(Ri): 14 12.50 16 <br /> 1030 1030 <br /> Test End Time(TF): 1030 ------ <br /> Final Reading(RF): 14 12.50 16 <br /> IHR IHR <br /> Test Duration(TF—T,): IHR --- <br /> Change in Reading(RF-Rj): 0 0 10 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria. <br /> Test Result: ® Pass Fail ® Pass ❑ Fail ® Pass ❑ Fail E01 Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, ind recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCT15IG THIS TESTING <br /> hereby certify that all the information contained in this report is true,accurate,a nd in full compliance with legal requirements. <br /> Technician's Signature: TC-)--j Date 4-28-2010 <br /> State laws and regulations do not currently require testing to be perf rmed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />