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' ^ • � _ � �� � cry �� -n <br /> January 2006 <br /> Spill Bucket Testing Report Form AU1 �G - <br /> This form is intended for use by contractors performing annual testing of UST spill containment s". ltrV$C :Aleted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittc{ i�o�t �e,1P*Yagency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: S B GAS & MARKET I Date of Testing: 7/11/2018 <br /> Facility Address: 515 W. 11TH STREET TRACY , C A 9 5 3 76 <br /> Facility Contact: KEN Phone: <br /> Date Local Agency Was Notified of Testing:6/25/2018 <br /> Name of Local Agency Inspector(f present during testing): ZUNA B <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez ❑Ed Stearns <br /> #8883064-UT #8883059-UT #8883072-UT #8883080-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 ®Direct 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: 14 1/4 15 1/4 14 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1208 1208 1208 <br /> Initial Reading(RI): 13 1/4 14 1/4 13 3/4 <br /> Test End Time(TF): 1308 1308 1308 <br /> Final Reading(RF): 13 1/4 14 1/4 13 3/4 <br /> Test Duration(TF—TI): H O U R <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 /> ALL MEASURED 5 GALLONS + <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: 7/11/2018 <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 />