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• • . <br /> 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(if applicable), should be provided to the facility owner/operator for submittal tc9; _-",(0�, -i4k'h�atory agency. <br /> 1.FACILITY INFORMATION l` <br /> Facility Name: TIWANA GAS&FOOD I Date of Testing: 6/29/2018 <br /> Facility Address: 1210 E HAMMER LANE STOCKTON,CA 95213 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:5/30/2018 <br /> Name of Local Agency Inspector(if present during testing): ZUNA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-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 [I Direct Bury E]Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 13 1/2 15 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0900 0900 0900 <br /> Initial Reading(Rj): 13 - 13 - 14 - <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 13 - 13 - 14 - <br /> Test Duration(TF—TI): H O U R <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 91 TANK 5 GALLONS <br /> 89&87 APPROX 4 1/2 GALLONS <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: 6/29/2018 <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 />