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b a <br /> 0 <br /> EPs via uary 2006 <br /> Spill Bucket Testing Report Form Ewriwoww <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment stru m 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: WEST LANE FUELS Date of Testing: 7-25-19 <br /> Facility Address: 3300 WEST LANE STOCKTON, CA 95204 <br /> Facility Contact: Phone: 466-1682 <br /> Date Local Agency Was Notified of Testing:6-28-16 <br /> Name of Local Agency Inspector(af present during testing): SJV VICKI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°d 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: 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 E]Direct Bury ®Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump ❑ Contained in Sump ❑ Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 1 I <br /> Bucket Depth. 14 14 1/4 <br /> Wait time between applying - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 <br /> Initial Reading(Ri): 13 13 <br /> Test End Time(TF): 10 10 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or <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 W. Date:-7-25-16— <br /> State <br /> ate: 7-25-16State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />