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N SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />Th is is intended,for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />i L A!''TT 1rV it V"12X4ATInN <br />Facility Name: RIPON SHELL 1 Date of Testing: 01-28-10 <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 :01-07-10 <br />Name of Local Agency Inspector (rf present during testing): SAN JOAQUIN CO MOONEY <br />rupTTNc Cf)NTRAC'TOR 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 />11 Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br />1 ['.TTT T nTrnvr. T rrvv r-Fwi- T4VT nD1%4ATT(1N <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br />2 91 <br />®Direct Bury <br />❑ Contained in Sump <br />3 <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />®Direct Bury <br />❑ Contained in Sump <br />Bucket Installation Type: <br />Bucket Diameter: <br />11 <br />11 <br />7DB <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />_ <br />Test Start Time (Ti): <br />900 <br />900 <br />Initial Reading (Rj): <br />12 <br />12 <br />Test End Time (TF): <br />1000 <br />1000 <br />Final Reading (RF): <br />12 <br />12 <br />Test Duration (TF — Ti): <br />I HOUR <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result: <br />Z Pass ❑ Fail <br />Z Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended jotlow-itp jor jauea 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: 1/28/10 <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 />