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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. FACIT,ITY INFORMATION <br />Facility Name: GAS DEPOT Date of Testing: 12-29-16 <br />Facility Address: 1330 E YOSEMITE AVE MANTECA CA 95240 <br />CC , k - <br />Facility Contact: Kevin Phone: 209-825-0f-21 <br />? e <br />Date Local Agency Was Notified of Testing :11-21-16 <br />Name of Local Agency Inspector (ifresent during testing) : <br />2. l'EN I I.N (i UUIV l KAU l UK I -N V UKIVIA l LUPI <br />Company Name: AFFORDA TEST 416 211 Street Galt, CA 95632 (209) 744-0112 A, r 116 <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 <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />15 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />930 <br />930 <br />930 <br />Initial Reading (Rj): <br />13 <br />13 <br />14 <br />Test End Time (TF): <br />1030 <br />1030 <br />1030 <br />Final Reading (RF): <br />13 <br />13 <br />14 <br />Test Duration (TF - TI): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />I JZ Pass ❑ Fail <br />I ® Pass ❑ Fail <br />❑ 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 <br />Date 12-29-16 <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 />8 <br />H <br />