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Ll <br />n <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 />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: EL DORADO FOOD SHELL I Date of Testing: 02-11-10 <br />Facility Address: 2320 NORTH EL DORADO BLVD STOCKTON CALIFORNIA95204 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO <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 ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: 1/16 <br />.. ... . ..::. . :7 <br />7 77,77,77 7 77 7 77 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />187 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />,Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Ti): <br />1330 <br />1330 <br />1330 <br />Initial Reading (Ri): <br />12 <br />12 <br />12 <br />Test End Time (TF): <br />1430 <br />1430 <br />1430 <br />Final Reading (RF): <br />12 <br />12 <br />12 <br />Test Duration (TF — Ti): <br />1 HOUR <br />I HOUR <br />I HOUR <br />Change in Reading (RF - Rj): <br />0 <br />1 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result: <br />E Pass ❑ Fail <br />Z Pass ❑ Fail <br />E Pass ❑Fail <br />❑ 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 />`!1 <br />Technician's Signature: �J <br />Date: 2-1 1-10 <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 />