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s® <br />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 L`Ad-IrF T9rV ilVl nIDXiATrnN <br />Facility Name: TRACY VALERO Date of Testin �� 10� 31 14..x. <br />Facility Address: 2375 TRACY BLVD TRACY CA <br />Facility Contact: I Phone: 925-915-0805 <br />Date Local Agency Was Notified of Testing: 10-27-14 p �Q�4 <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO Mick 1. Henry <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 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 E Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />11 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />A QPrr.r. RITCWFT TF.CTIN(: INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />2 <br />3 WASTE OIL <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 <br />Bucket Installation Type: <br />❑ Direct Bury <br />El Contained in Sump <br />❑Direct Bury <br />E] Contained in Sump <br />®Direct Bury <br />F] Contained in <br />Sump <br />F-1 Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />14 1/2 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />Test Start Time (Ti): <br />900 <br />Initial Reading (Rj): <br />13 <br />Test End Time (TF): <br />1000 <br />Final Reading (RF): <br />13 <br />Test Duration (TF — Ti): <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />❑Pass ❑ Fait <br />❑ Pass ❑ Fail <br />E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <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:10-31-14 <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 />