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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for ntractors performing annual licable), should be provided to the factesting of UST ility owner/operator for ill submittal to the local regulatnment structures. The ory agency.and <br /> printouts from tests (f app ), <br /> 1.FACILITY INFORMATION <br /> Date of Testing: 6-21-2017 <br /> Facility Name: JESSE & KUL PETRO ARCO <br /> Facility Address: 1711 E. YOSEMITE AVE MANTECA, CA 95336 <br /> Phone: <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing:5/25/2016 JOHN JUL 2 .+ 2011 <br /> Name of Local Agency Inspector(f present during testinp�: <br /> 2.TESTING CONTRACTOR INFORMATION - - _ r- TH <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112-FFp.fi q 16 <br /> ❑ Ed Stearns Zane A.Nimmo XXX David A. Winkler ❑ Felix G.Ramirez <br /> Technician Conducting Test: 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Hydrostatic ❑Vacuum ❑ Other <br /> FTest Method Used: ® y Equipment Resolution: 1/16" <br /> howsoms st Equipment Used: TAPE MEASURE, H2O <br /> Identify Spill Bucket(By Tank 1 87 <br /> 2 87-2 3 91 4 <br /> Number, Stored Product, etc. Direct B <br /> ❑ Direct Bury ❑ Bury <br /> ❑Direct Bury ❑ Direct Bury ® Contained in ❑Contained in <br /> Bucket Installation Type: ®Contained in Sump ® Contained in Sump SumpSum <br /> ' 1 11 11 <br /> Bucket Diameter: I <br /> Bucket Depth: <br /> 12 1/4 12 12 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1 <br /> 1 1 <br /> Initial Reading(Ri): <br /> 12 11 12 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): <br /> 12 11 12 <br /> Test Duration(TF—T�): <br /> HR HR HR <br /> Change in Reading(RF-Ri): <br /> 0 0 0 <br /> Pass/Fail Threshold or _- -- <br /> Criteria: <br /> Pasl, Fail ( Pass ` ❑Fail Pis ❑Ea�i ❑piss . ❑`Fsil<:. <br /> Test Result. '� .. ~� <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 /> chnician's Signature:_ W. 6-21-17 <br /> However, local requirements may be more stringent. <br />