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Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. Ae co4gt a Q m and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal tot re latory agency. <br /> MOR <br /> 1. FACILITY INFORMATION <br /> Facility Name: SAN JOAQUIN COUNTY JAIL Date of Testing: 11-8- <br /> Facility Address: 7000 CANLIS BLVD. FRENCH CAMP, CA 95231 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:10-10-13 <br /> Name of Local Agency Inspector(if present during testing): Thuy <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Gait,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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Lt <br /> Identify Spill Bucket(By Tank 1 DIESEL NORTH 2 3 4 DIESEL SOUTH <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury <br /> Direct Bury Z Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> ❑Contained in Sump E]Contained in Sump Sump Sum <br /> Bucket Diameter: 11 I 1 <br /> Bucket Depth: 9 3/4 11 3/4 <br /> Wait time between applying <br /> V_acuum/water and start of test: - <br /> Test Start Time(Tj): 0925 0925 <br /> Initial Reading(R1): 11 11 <br /> Test End Time(TF): 1025 1025 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ED Dass ❑Fail ❑ Pass ❑Fail` ❑ Pass ❑Fail Z 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:_ Date: 11-8-13 <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 />