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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the facility owner.%perator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: JESSE & KUL PETRO ARCO I Date oftesting: 6/13/2016 <br /> Facility Address: 1711 E. YOSEMITE AVE MANTECA, CA 95336 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:5/25/2016 <br /> Name of Local Agency Inspector(if present during testing): VICKIE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"1 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 INFORMATIO <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑Othe <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By lank 1 87 2 87-2 P-9F <br /> 4 <br /> Number,Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: El Direct Bury ❑ Direct Bury ®Contained in ❑Contained in <br /> ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 12 1 4 12 12 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1420 1420 1420 <br /> Initial Reading(RI): 11 1/2 11 1/8 11 3/4 <br /> Test End Time(TF): 1520 1520 1520 <br /> Final Reading(RF): 11 1/2 11 1/8 11 3/4 <br /> Test Duration(TF—Tj): HR HR HR <br /> Change in Reading(RF-Rj): 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 follo�-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:6-20-16 <br /> However,local requirements may be more stringent. <br />