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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 fi-om 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: COUNTRYCLUB 761-26-20171—Date of Testing: <br /> Facility Address: 2575 COUNTRYCLUB STOCKTON CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): GARRET <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 h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank I 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) f <br /> El Direct Bury ❑ Direct Bury Direct Bury —Direct Bury <br /> Bucket Installation Type: ® ® Contained in ❑Contained in Contained in Sump ® Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I I <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 930 930 930 <br /> Initial Reading(Ri): 11.75 12.25 _ 12.50 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 11.75 12.25 12.50 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: IL ® Pass ❑ Fail 1 ® Pass ❑Fail 2 Pass' ❑ Fait ❑ 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 with legal requirements. <br /> Technician's Signature: V` —j Date 1-26-2011 <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 />