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E <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUL 19 2017 <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/operator foFMkin,itp#to the local regulatorkTi4ncy. <br /> 1. FACILITY INFORMATION (--- <br /> Facility Name: JESSE & KUL PETRO ARCO I Date of Testing: 6-21-2017 <br /> Facility Address: 1711 E. YOSEMITE AVE MANTECA, CA 95336 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:5/25/2016 <br /> Name of Local Agency Inspector(if present during testing): JOHN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 1 Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns Zane A.Nimmo XXX 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(Bi,Tank 1 87 2 87-2 3 91 4 <br /> Number, Stored Producl, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: l 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(Tj): 1 1 1 <br /> Initial Reading(Rt): 12 11 12 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): 12 11 12 <br /> Test Duration(TF—T,): HR HR HR <br /> Change in Reading(RF-Rt): 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 Ncith legal requirements. <br /> chnician's Signature:_ W. 6-21-17 <br /> However,local requirements may be more stringent. <br />