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t <br /> Alk <br /> ASG 0 8 CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment struc(ur w �-cbmpleted 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: S B GAS & MARKET I Date of Testing: 7/12/2016 <br /> Facility Address: 515 W. 11TH STREET TRACY, CA 95376 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:6/28/16 <br /> Name of Local Agency Inspector(f present during testing): FATINAH <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 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): 1215 1215 1215 <br /> Initial Reading(RI): 13 1/4 14 1/4 13 3/4 <br /> Test End Time(TF): 1315 1315 1315 <br /> Final Reading(RF): 13 1/4 14 1/4 13 3/4 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Yaff <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> BUCKETS 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 7-12-16 <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 />