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IN <br /> Spill Bucket Testing Report Form JLNY9ry 2006 FIT 6e <br /> This form is intended for use by contractors performing annual testing of UST spill containment struct .T ,how d er'n and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the locbl r0g ibtory tlgency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: QUICK N EASY MART I Date of Testing: 4/25/2016 <br /> Facility Address: 2057 S. ELDORADO ST. STOCKTON, CA 95206 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/11/2016 <br /> Name of Local Agency Inspector(fpresent during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo M Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': M ICC Service Tech. M SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 <br /> Number, Stored Product, etc. <br /> M Direct Bury ❑Direct Bury M Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 1 I <br /> Bucket Depth: 12 1/4 13 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1045 1045 <br /> Initial Reading(Rj): 11 1/4 12 3/8 <br /> Test End Time(TF): 1145 1145 <br /> Final Reading(RF): 11 1/4 12 3/8 <br /> Test Duration(TF—TI): HR HR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ®.Pass [ Fail. []"Pass ❑Fail Pass ❑Fail Pass <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 /> Technician's Signature Date: 4-25-16 <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 />