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S WRC $ Tan ., ._` 2006 <br />Spifl Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures.` The d6Mpleted forrtr ° 7 <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the'local regulatory agency <br />1. FACILITY —INF ORMATION <br />Facility Name: SHOP N GO Date of Testing: 5/10/2016 <br />Facility Address: 4511 PACIFIC AVE. STOCKTON , CA 95207 <br />Facility Contact: Mo Phone: <br />Date Local Agency Was Notified of Testing :4-25-16 <br />Name of Local Agency Inspector (f present during testing): FAHTINA <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: ❑ 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 <br />.i..ss as�a� L V Ll'L` 1 1 L' � 1 ur (a 11v r V��A I IU1V <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 91 <br />2 3 87 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct B ® Direct Bury <br />Bury <br />❑ Contained in Sump 0 Contained in <br />SumSum11 <br />15 3/4 <br />'- -- <br />❑ Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />14 3/4 <br />-_ <br />Test Start Time (Ti): <br />0930 <br />0930 <br />Initial Reading (Rr): <br />13 3/4 <br />14 3/4 <br />1030 <br />Test End Time (TF): <br />1030 <br />Final Reading (RF): <br />11 3/4 <br />14 3/4 <br />Test—_- <br />uration (TF — TI): <br />HR <br />HR HR <br />0 <br />HR <br />Change in Reading (RF - Rj): <br />-2.00" <br />Pass/Fail Threshold or <br />Criteria: <br />-- <br />-- -- <br />❑ Pass ❑Fail ®Pass ❑ Fail <br />__ <br />Test Result: <br />❑ Pass ® Fail <br />❑Pass ❑Fall <br />a „6uue terror ca resang, ana recommended follow-up for failed tests) <br />91 SPILL BUCKET FAILED - WAYNE HENDERSON - H M C <br />WILL REPLACE BUCKET. <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 t -- Date: 5-10-16 <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 />