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' <br /> Spill Bucket Testing Report Form SWRCB,January 2006 <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: KWIK SERVE Date of Testing: 8-17-11 <br /> Facility Address: 950 W 11TH STREET TRACY CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(rfpresent during testing: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST416 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: h20 and tape measure Equipment Resolution: 1/16 <br /> w.,, �. .x . <br /> Identify Spill Bucket(By Tank 1 87 2 91 3DSL 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 I 1 1 l <br /> Bucket Depth: 13 12 16 <br /> Wait time between applying <br /> vacuum/water and start of test: - -- -- <br /> Test Start Time(Tj): 9 9 9 <br /> Initial Reading(Ri): 12 12 15 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 12 12 15 <br /> Test Duration(TF—Ti): ]FIR IHR IHR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: jj E Pass ❑ Fail 2 Pass ❑ Fail ® Pass El 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 /> Tc-� <br /> Technician's Signature: Date 8-17-11 <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 />