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REGEwEu <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form FEB.16 7016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structure . <br /> %PI <br /> AL <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the <br /> W <br /> r <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 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 H2O Equipment Resolution: 1/16 <br /> TMW,7--T7_r7v777TMM. v. <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury <br /> ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ElContained in El Contained in <br /> ❑Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: I 1 i l <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—Tj): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: 1 ® Pass ❑Fail I ® Pass ❑Fail I ❑ Pass ❑Fail I ❑ Pass ❑Fail <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 />