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j <br />..'�1. SWRCB, January 2006 <br />gar 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 (f 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 Date of Testing: 07-27-12 <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 :07-01-09 <br />Mame of Local Agency Inspector (f present during testing): SAN JOAQUIN CO JEFF WONG <br />A F - {; a <br />2. TESTING CONTRACTOR INFORMATION - <br />CompanyName: AFFORDA TEST 416 2"d Street Galt CA 95632 <br />,(209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: <br />❑ Lyle D. Nimmo ❑ Zane A. Nimmo... ❑ <br />David A. Winkler Felix G. Ramirez <br />5249115 -UT 5263322 -UT <br />5263.373 -UT 5273934 -UT <br />Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic ❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE.H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />1 87 2 DIE <br />3 4 <br />-Number, Stored Product, etc.' <br />rt 5T it eac, <br />E�efin llatiior pe: <br />Direct Bury <br />® Direct Bury <br />Direct Bu <br />❑ rY <br />❑ Contained in <br />Direct Bury <br />❑ Contained in <br />❑ Contained in Sump <br />❑ Contained in Sump <br />SumpSum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />900 <br />900 <br />Initial Reading (RI): <br />14 <br />14 <br />Test End Time (TF): <br />1000 <br />1000 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF -- TI): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />P s Fail r`eshold` dr <br />Criteria: 5 zi' <br />0 <br />0 <br />0 <br />0 <br />Test Resu <br />Pass � ❑ Fail . <br />[D , Pass: Q Fail <br />>, ❑ Pass <br />El Fail <br />❑Paso ©Fail , <br />Comments -' (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's. Signature: Date: 7-27-12 - <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 />