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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> Thisform is intended for use by contractors perforrrring annual testing; of USTspill containment structures. The completed form and <br /> printouts f mom tests (lf applicable), should be provided to tire./acility ownerioperator.lbr submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : WOODBRIDGE ARCO Date ofTestin : 04-23- 18 <br /> Facility Address: 18806 LOWER SACRAMENTO RD , WOODBRIDGE, CA 95258 <br /> Facility Contact: YVONNE Phone: 209-339-8238 <br /> Date Local Agency Was Notified ofTesting: 03 -23- 18 <br /> Name of Local Agency Inspector (if present during testing) : SAN JOAQUI`J CO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d Street Galt, CA 95632 (209 ) 744-0112 Fax : (209) 744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane .,1. Nimmo ❑ David A. Winkler Felix G. Ramircz <br /> 8883080-U7 8883064-UT 8883059-UT 8883072 -UT <br /> Credentials ' : ® ICC Service Tech . ® SWRCB Tank Tester <br /> 3 . SPILL BUCKET TESTINGINFORNIA'1TION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : TAPE ! H2O Equipment Resolution: 1116 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury E] Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in Sump Contained in Sump ® Contained in ❑ Contained in <br /> SumpSump <br /> Bucket Diameter: 11 11 11 <br /> BucketDepth : 13 13 13 <br /> Wait time between applying <br /> vacuutnlwater and start of test: <br /> Test Start Time (Tr) : 935 935 935 <br /> Initial Reading (Ri) : 12 12 12 <br /> Test End Time (Tr): 1035 1035 1035 <br /> Final Reading (RF) : 12 12 IZ <br /> Test Duration (TF -- Tr) : t HOUR I HOUR 1 HOUR <br /> Change in Reading ( RF - Rr): 0 0 0 <br /> Pass`Fai1 Threshold or _ <br /> Criteria : <br /> Test Result: 0 Pass ❑ Fail ® Pass [] Fail in Pass <br /> ❑ . Fart Pas <br /> ❑ s ❑. Fail <br /> C't3IIlT17entS — (include in/brmation on repairs made prior to testing, and recom»tended follow-up for,/ailed tests) <br /> OPW BUCKETS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certiljy that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br /> 4e f ~^r <br /> Technician ' s Signature: J. t Date :04-23 - 18 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirement <br /> may be more stringent. <br />