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k <br /> E �;�;a SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> Thzs f�rtxt rs arttepded�Jntcontractors performing annual testing of UST spill containment structures. The completed form and <br /> v + rtYttotrt florh ti?sts. }`app:cable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Stop N Shop Date of Testing: 6/16/17 <br /> Facility Address: 1856 COUNTRY CLUB BLVD STOCKTON,CA 95204 <br /> Facility Contact: Sonny Phone: <br /> Date Local Agency Was Notified of Testing:6/9/17 <br /> Name of Local Agency Inspector(if present during testing): <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: ®Ed Stearns ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-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: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> ❑ Contained in Sump E]Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: - <br /> Test Start Time(Ti): 130 130 <br /> Initial Reading(Rj): 12 12 <br /> Test End Time(TF): 230 230 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <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 with legal requirements. <br /> Technician's Signature: ` ' -' Date:6-16-17 <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 />