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Parkwood Gas& Food 2 98888157 p.7 <br /> }�)� Sb1k12CIB,January 2006 <br /> Spill Bucket Testing Report For <br /> ,Thisform is intended for use by contractors performing annual testing of UST spill containment sipW1 i iii4 npfeted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submit 1� lsdl ktld agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TIWANA GASDate of Testing: 6-26-17 <br /> Facility Address: 1210 E. HAMMER LANE STOCKTON, CA 95213 <br /> Facility Contact: PAUL Phone: 209-477-3111 <br /> Date Local Agency Was Notified of Testing:5,124/2016 <br /> Name of Local Agency inspector(if present during testing): Elena <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: ❑ Fd Stearns ❑ Zane A.Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br /> 8184188 I 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑ Direct Bury <br /> ❑ Direct Bury ❑] Direct Bury <br /> Bucket Installation Type: ® Contained in ❑ Contained in <br /> ®Contained in Sump ®Contained in Sump <br /> Sump Sum <br /> Jucket Diameter: l l 1 l 11 <br /> Bucket Depth: 13 12 1/2 14 7/8 <br /> Wait time between applying <br /> vacuum!water and start of test: <br /> Test Start Time(Ti): 10 10 10 <br /> Initial Reading(Rj): 12 11 1/2 14 <br /> Test End Time(TF): 11 11 11 <br /> Final Reading(RF): 3 11 1/2 14 <br /> Test Duration(TF—Tt): HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 j <br /> Pass;Fail Threshold or _ <br /> Criteria <br /> Test Res1llt. F 1K.i l _D . ., I' 5; . ❑ <br /> Comments— (include information on repairs made prior to testing, and recommendedfollow-app 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 . <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local <br /> requirements may be more stringent. <br /> Received Time—Ju1. 25. -2018-10:46AM No, 3918 <br />