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2006 <br />Spill Bucket Testing Report Form JAN 2 5 2016 <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 flqdagency. <br />I FACTI.TTV ii MUNIATiON HEALTH DEPARTMENT <br />Facility Name: GAS DEPOT I Date of Testing: 12-30-15 <br />Facility Address: 1330 E YOSEMITE AVE MANTECA CA <br />Facility Contact: Kevin Phone: <br />Date Local Agency Was Notified of Testing :11-25-15 <br />Name of Local Agency Inspector (if present during testing): ELANA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"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 ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester N <br />2 CPTI.I. RI[Tf KF.T TF.CTIN(, iNFnRMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: 1/16 <br />2 91 <br />3 DSL <br />4 <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />® Direct Bury <br />Bucket Installation Type: ❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />® Contained in <br />Sum <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />11 <br />Bucket Depth: 14 <br />14 <br />15 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): 930 <br />930 <br />930 <br />Initial Reading (Ri): 13 <br />13 <br />14 <br />Test End Time (TF): 1030 <br />1030 <br />1030 <br />Final Reading (RF): 1 13 <br />13 <br />14 <br />Test Duration (TF — Ti): IHR <br />IHR <br />IHR <br />Change in Reading (RF - Rt): 0 <br />0 <br />0 <br />Pass/Fail Threshold or 1/16 <br />Criteria: <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® 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: <br />Date 12-30-15 <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 />