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Feb 05 16 05:37a Kevin Hur 209-825-1532 P.8 <br />0 Ar,%Ell I.. elk <br />REU IV <br />swRcBFja45o416 <br />SpiH Bucket Testing Report Form 171 NTAL <br />This form is intended for use by contractors performing annual testing of UST spill containment structures.A, V! EN T <br />printow,from tests (if applicable), should beprovided to the facility ownervapaatorfor submittal to the local rev, wag� <br />Faeffity'Name: GAS DEPOT Date of i;;Fng: 12-36-15 <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 />Company Name: AFFORDA TEST 416 tad Street Gait CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo [] Zane A. Nimmo M David A. Winkler F-3 Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': (E [CC Service Tech. [E SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFO TION <br />Test Method Used: Hydro Vacuum —Other' <br />Test Equipment Used: h20 d tape measure Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />.-1 87 <br />2-91 <br />3 DSL <br />4 <br />Number, Stored Product, !Lc.2,, <br />-1@ <br />-0—Direct <br />0 Direct Bury <br />Direct Bury <br />Direct Bury <br />El Contained in <br />Bury <br />El Contained in <br />Bucket Installation Type: <br />D Contained in Sump <br />F] Contained in Sump <br />Stun <br />Stine <br />Bucket Diameter. <br />I I <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />15 <br />Wait time between applying <br />-- <br />- <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />930 <br />930 <br />930 <br />Initial Reading (Ra): <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 - Tj): <br />lHR <br />1HR <br />lHR <br />Change in Reading (RF -RT):— <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />1/16 <br />1/16 <br />1/16 <br />Criteria: <br />Test Result: <br />PM 0 Fall <br />0 Pass ❑ Fail <br />0 pan Fag 0 Pass 0 Fail <br />Code in on repairs made prior to �� moa recummerfucu"Jumments - Onclu Hin . <br />CERTIFICATION OF TECiiNiCiAN RESPONSIBLEFOR CONDU iNGTHIS TESTING <br />I hereby (!Crt* that all the information Contained in this report is true, accurate, sad in full compliance with lepl requirements. <br />Technician's Signature: T6—) 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 />