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.' A. 0 <br /> 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 /> rintouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: GAS DEPOTDate of Testing: 12-29-16 <br /> Facility Address: 1330 E YOSEMITE AVE MANTECA CA 95240 <br /> Facility Contact: Kevin Phone: 209-825-0332 <br /> Date Local Agency Was Notified of Testing:11-21-16 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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 /> Credentials': ®ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number,Stored Product, etc) <br /> ®Direct B ' Direct B ❑Direct Bury <br /> Bucket Installation Type: ®Direct Bury ury❑Contained in El Contained in <br /> ElContained in Sump El Contained in Sump <br /> SUMD Sum <br /> cket Diameter: 11 11 11 <br /> ucket Depth: 14 14 15 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(Ti): 930 930 930 <br /> Initial Reading(Ri): 13 13 14zj . <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 13 13 14 ,4 <br /> LTH <br /> Test Duration(TF—Ti): IHR IHR IHR <br /> Change in Reading(RF-Rz): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: :=Fail Pass ❑Fail Pass ❑Fail ❑ 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 /> echnician's Signature: 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 />