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4L. <br /> Spill Bucket Testing Report Form M nary 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment surdle-. pl and <br /> printouts from tests(ifopplicable), should be provided to the facility ownerloperatorfor submittal to the,l6eat-regularmy-agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: RIPON SHELL I Date of Testing: 01-25-16 <br /> Facility Address: 341 EAST MAIN STREET RIPON CALIFORNIA <br /> Facility Contact: ANGLE Phone: 510-552-4822 <br /> Date Local Agency Was Notified of Testing:12-23-15 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO STACI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"1 Street Gait,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: 0 Lyle D.NimmoEl Zane A.Nimmo ❑ David A.Winkler Z Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. Z SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic Ej vacuum E]Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc.2 <br /> Z Direct Bury Z Direct Bury Ej Direct Bury El Direct Bury <br /> Bucket Installation Type: 0 Contained in Sump 0 Contained in SUMP El Contained in ❑Contained in <br /> Sump Sump <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): 900 900 <br /> Initial Reading(Ri): 12 12 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—Ti): I HOUR I HOUR <br /> F—Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: Fail <br /> Test Result Z Pass ® Pass El Fai=l [:] Pass <br /> [:1 El Fail El Pass <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ®PW BUCKETS <br /> - FLAPPERS <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: 1-25-16 <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 />