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INED <br /> J U� 2 3 �.1CV ILICCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill con pNV4R@N*&W-fAL-kA99J#m and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittd�R Ea*T(atory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: NATIONAL PETROLEUM I Date of Testing: 5/2/2017 <br /> Facility Address: 713 N. EL DORADO ST. STOCKTON, CA 95202 <br /> Facility Contact: Nilesh I Phone: 209-235-6262 <br /> Date Local Agency Was Notified of Testing:4/19/2017 <br /> Name of Local Agency Inspector(if present during testing): STACY R. <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 ElDirect Bury ❑Direct Bury <br /> 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): 1305 1305 1305 <br /> Initial Reading(Ri): 12 3/4 12 5/8 15 <br /> Test End Time(TF): 1405 1405 1405 <br /> Final Reading(RF): 12 3/4 12 5/8 15 <br /> Test Duration(TF—Tj): 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 /> Comments—(include information on repairs made prior to testing, and recommended follow-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:-5-2-17 <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 />