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1. . 0 • RECEIVED <br />OCT WSIIA,14anuary 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containm <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal tot 'agency. <br />1 FACTT.TTV TNMUMA'TTnN <br />Facility Name: TRACY VALERO Date of Testing: 09-29-14 <br />Facility Address: 2375 TRACY BLVD TRACY CA <br />Facility Contact: HAKAM Phone: 209-835-5358 <br />Date Local Agency Was Notified of Testing :09-23-14 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO STACY <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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester Y <br />A CPTT T. RTTCKFT TFCTTNC_ TNFORMATTnN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 89 2 91 3 WASTE OIL 487 <br />Number, Stored Product, etc. <br />Bucket Installation Type:❑ <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury ® Direct Bury <br />Contained in <br />El Contained in Sump Sump <br />® Direct Bury <br />El in <br />Sum <br />Bucket Diameter: <br />11 <br />11 11 <br />11 <br />Bucket Depth: <br />13 <br />13 14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />- <br />_ <br />Test Start Time (Ti): <br />915 <br />915 915 <br />915 <br />Initial Reading (Rj): <br />12 <br />12 13 <br />13 <br />Test End Time (TF): <br />1015 <br />1015 1015 <br />1015 <br />Final Reading (RF): <br />12 <br />12 13 <br />13 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR 1 HOUR <br />1 HOUR <br />Change in Reading (RF - Rj): <br />0 <br />0 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑> Fail <br />0 Pass ❑ Fail Z Pass []Fail <br />Z Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for jailed 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:09-29-14 <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 />