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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 /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: KNIFE RIVER DSS I Date of Testing: 7-28-14 <br /> Facility Address: 655 WEST CLAY AVE STOCKTON CALIFORNIA <br /> Facility Contact: JOHN Phone: 209-948-0302 <br /> Date Local Agency Was Notified of Testing: 7-14-14 <br /> Name of Local Agency Inspector(f present during testing): SJC <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo X❑ David A.Winkler Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br /> s. <br /> Identify Spill Bucket(By Tank 1 87 2 DIE 3 4 <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury ElDirect Bury ElDirect Bury <br /> Bucket Installation Type: El Contained in ❑ Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 <br /> Initial Reading(RI): 14 14 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 14 14 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: 0 Pass ' ❑Fail Z Pass ❑Fail ❑ Pass ❑Fail ❑, Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for fai <br /> OPW BUCKETS <br /> -1A N 0 9 2915 <br /> EWIRONMENTALH L <br /> PERMMSERVICES <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 /> Te hnician's Signature: .Date: 7-28-14 <br /> ' tate laws and regulations do not currently require testing to be performed by a qualified contractor.However, local <br /> requirements may be more stringent. <br />