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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO Date of Testing: j7w4 <br /> Facility Address: 2908 W BEN HOLT STOCKTON CA <br /> Facility Contact: Phone: law <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): FATIMA 0! <br /> 2. TESTING CONTRACTOR INFORMATIONg, w=max <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 1 87 2 91 3 87 SLAVE 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bury F-1DirectBury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in ❑Contained in <br /> E]Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 I 1 11 <br /> Bucket Depth: 15 15 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1 1 1 <br /> Initial Reading(RI): 14 13.50 13.50 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): 1 14 12 14.40 <br /> Test Duration(TF—TI): IHR 1 HR IHR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail 10 Pass ❑Fail 0 Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW ALL PASS <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 1-29-15 <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 />