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Parkwood Gas& Food 2 98888157 <br /> IVth.r: <br /> ,l U 1 `kRd8January 2006 <br /> Spill Bucket Testing Report Form <br /> ENVIRONMENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill containment st( l orm and <br /> printouts from tests(if applicable), should be provided io the facility mvner/operator for submittal'to"'hii local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: TTWANA GAS&FOOD Date of Testing: 68/15 <br /> Facility Address: 1210E HAMMER LANE STOCKTON.CA <br /> Facility Contact: PAUL Phone: <br /> Date Local Agency Was Notified of Testing:5/18./15 <br /> Name of Local Agency Inspector(ifpresent during testing): FATINHA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 Fax.(209)744-0116 <br /> Technician: JZEd Steams ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-UT 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ®SVVRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Scored Product, etc.) <br /> Q Direct Bury E3 Direct Bury ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Z Contained in Contained in <br /> Contained in Sump Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1230 1230 1230 <br /> Initial Reading(111): 12 12 14 <br /> Test End Time(TF): 1330 1330 1330 <br /> Final Reading(RF): 12 12 14 <br /> Test Duration(Tx—T�: IHR l HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1116 1/16 1/16 <br /> Criteria: <br /> Te t3tllt. Pass . _[�F&il :i Pass:: ❑T-10 Pass []F'a l ❑ Pass [a F iF" <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: fit' Date:618/15 <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 /> Received Time Jul, 25. 2018 10:46AM No- 3918 <br />