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r RECEIVED JAN 2 S 2016 S ill Bucket Testing Report Form HEALTH D pART LENT p g This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION — P Facility Name: GAS DEPOT Facility Address: 1330 E YOSEMITE AVE MANTECA CA Facility Contact: Kevin Phone: Date Local Agency Was Notified of Testing :11-25-15 Name of Local Agency Inspector (af present during testing): ELANA Date 12-30-15 2. TESTING CONTKAC:TUK M k UMVI A I JLUi. Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester rwra,�wram�r a TiAAT Comments — include injormation on repairs maae riur w dr��6.� PNP46 • ��••••••�••»�» _ - - CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: v Date 12-30-15 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. J.w7SiLLDv®..sv:.x BaJ�sgs... ----- ❑ Vacuum Other Test Method Used: ® Hydrostatic Equipment Resolution: 1/16 Test Equipment Used: h20 and tape measure Identify Spill Bucket (By Tank 1 87 2 91 3 DSL 4 Number, Stored Product, etc. Direct Bury Direct Bury ® Direct Bury ® Direct Bury ®Contained in ❑ Contained in Bucket Installation Type: ❑ Contained in Sump Sump ❑ Contained in Sum Sum Sum Bucket Diameter: 11 11 11 Bucket Depth: 14 14 15 Wait time between applying -_ -- vacuum/water and start of test: Test Start Time (Ti): 930 930 930 Initial Reading (Ri): 13 13 14 Test End Time (TF): 1030 1030 1030 Final Reading (RF): 13 13 14 Test Duration (Tp—Ti): IHR IHR 1HR Change in Reading (RF - Ri): 0 0 0 Pass/Fail Threshold or 1/16 1/16 1/16 Criteria: Test Result: ®;Pass Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail Comments — include injormation on repairs maae riur w dr��6.� PNP46 • ��••••••�••»�» _ - - CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: v Date 12-30-15 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.