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RE VED <br /> Al <br /> -Y.ft03r4rT ary 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containmetFNVJR1i W-cte44feALT <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to thrivm, grAt(q#gr ency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Pacific Service Station Date of Testing : 08 -3147 <br /> Facility Address : 6131 PACIFIC AVE STOCKTON CALIFORNIA 95207 <br /> Facility Contact : DAVE Phone : 209-475 -9842 <br /> Date Local Agency Was Notified of Testing : 07-2047 <br /> Name of Local Agency Inspector (fpresent during testing) : SAN JOAQUIN CO ALAINA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name : AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744 -0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br /> 8184188 8211269 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 H2O Equipment Resolution : 1 / 16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ❑ Direct Bury <br /> ® Direct Bury ® Direct Bury I <br /> Bucket Installation Type : ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 11 11 1 /2 <br /> Wait time between applying <br /> vacuum/water and start of test : <br /> Test Start Time (TI) : 930 930 930 <br /> Initial Reading (RI) : 11 11 11 <br /> Test End Time (TF) : 1030 1030 1030 <br /> Final Reading (RF) : 11 11 11 <br /> Test Duration (TF — TI) : 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading (RF - RI) : EOPass <br /> 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: ❑ 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 /> OPW BUCKETS <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 /> er�� <br /> Technician 's Signature :_ Date : 8-3147 <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 />