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pmz��M <br />Thi.vftwm is hitendedJbi- use by conlractors performitig onowul of TJUspill comahimew xtruclures. rhe completedform and <br />prhryow,cftom tests fif cippticablc,)..vhottidlvprovi(ILd to rhefiacilitj' to the local r4.p1a1o1j- agencV. <br />1. FACILITY INFORMATION <br />Facility Name, LJNFi ED PACIFIC #5446 - JIFFY LUBE Elate of Tesi�itt <br />5-19-17 <br />Facility Address-, 1403 COUNTRY CLUB STOCKTON CA 95204 <br />Facility Contact: one -- <br />Date Local Agency Was Notified of Testing:5- 10- 17 <br />Narne of Local Agency Insptetor Jiftresem dia-inn teeing): siv <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDAM-ST 416 2nd Street Galt, CA 95632 <br />(209) 7,14-0112 Fwx, (209) 744-0116 <br />Technician Conducting Test: <br />Credentials': Z ]CC Service Tech <br />El Ed Steams El Zane A. Nimnio 0 David A. Winkler 0 Felix G. Ramirez <br />81841SS 5263322 -UT 5263373 -UT 5273934 -UT <br />SWRCB Tank, Tester <br />3. SPILI, BUCKET TESTING IN `ORI- <br />VaCLIUM F1 Other I <br />Test Equipment Used,:, 1120 and tape measure <br />Equipment Resolution: 1116 <br />---- <br />ldentify Spill Buck (By TwA <br />Number, Stored P(advcl, e1c.) <br />I WAI�fC-01L <br />—2 <br />Bucket Install -mon Type: <br />❑Wry <br />Direct Bury <br />Contained In Sump <br />Direct Bury <br />Contained it) sump <br />Contained'in <br />Sump <br />Direct Bur'�. <br />Contained in <br />Sump <br />Bucket DiaMC <br />Bucket Depth: <br />Wait time between applying <br />vacuum Avater and start of test: <br />Test Stan Time (TI): <br />16 <br />o""', <br />J <br />Initial Reading (Rj); <br />15 <br />Test End Time (TF): <br />2 <br />1/16 <br />L[E]Pass <br />Final Reading (Rr)- <br />Tem Duration (Tr- Tt): <br />Change in Reading (Rp - Rl)-- <br />IHR - <br />0 <br />0 <br />Pas ?Fail Threshold or <br />Criteria-,es <br />Ut6 <br />1116 <br />Test Rult: <br />0 Pass 0 Fail <br />El Pass [:1 Fail <br />Q r�aii 10 <br />ass El Fail <br />Comments — Onchide information on repairs made priar to leming. and recommen Ldfi <br />'6UCKET FAILED. RIP ON RUBBER PORTION ON' CNI tk-'A'STE 011, BUCLKET LID, NF1 DS REPLACE AND RETEST. <br />(TIRTIFICATIONOF TECHNICIAN Rl,'."()N*S1 ULE FOR CONI)UCTIN"C. THIS T"TING <br />I hfrebi cc riify that all the inr4rnimfion contained in this rcrMI't iR Inas, wCcurnte.H1Ld in full ri)mRI[Anccuith legal requirements - <br />Technician's Signature- --j Date: 5-19-17 <br />State laws and regulations do not currently require testim, to be perfonmd by a qualified contractor. However, local reqvirCr"Crits <br />may be more stringent. <br />