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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form 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: WATERLOO GAS&LIQUOR 76 Date of Testing: 10-19-2010 <br /> Facility Address: 5611 E WATERLOO RD STOCKTON CA <br /> Facility Contact: PAUL Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRET <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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 /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury ®Direct Bury F-1DirectBury <br /> Bucket Installation Type: [—] Contained in El Contained in <br /> ❑ Contained in Sump ❑Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 10 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: - <br /> Test Start Time(Ti): 12 12 12 <br /> Initial Reading(Rj): 9.50 11 11 <br /> Test End Time(TF): 1 1 1 <br /> Final Reading(RF): 9.50 11 11 <br /> Test Duration(TF—Tj): IHR 1 HR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Teat Result: ® Pass ❑Fail Pass ❑Fall 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: TC-)--j Date 10-19-2010 <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 />