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4.i <br /> AUG 14 �O§ VRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill coutpi.nment structures.The completed form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator j6;submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: WEST LANE FUELS I Date of Testing: 7/10/2017 <br /> Facility Address: 3300 N. WEST LANE STOCKTON, CA 95204 <br /> Facility Contact: Sharon Phone: 466-1682 <br /> Date Local Agency Was Notified of Testing:6/24/2017 <br /> Name of Local Agency Inspector(fpresent during testing): STACY R. <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 ConductingTest: El Ed Stearns ® Zane A.Nimmo El David A. Winkler ❑ Felix G.Ramirez <br /> 8184188 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, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ❑Direct Bury ®Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> ❑Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 7/8 14 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1010 1010 <br /> Initial Reading(R,): 12 7/8 13 3/4 <br /> Test End Time(TF): 1110 1110 <br /> Final Reading(RF): 12 7/8 13 3/4 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑Fail Z 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: 7-10-17 <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 />