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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 fibrin and <br />printouts from tests (if applicable), should be provided to the, facility owner/operator for submittal to the local regulatory agency. <br />I IRA ('TT .TTV TNTi "D A4 A 'TT"W <br />Facility Name: � KISHIDA TRUCKING <br />Y <br />Date of Testing: 11-06-09 <br />Facility Address: 1725 ACKERMAN DRIVE <br />Facility Contact: KELLIE Phone: 209-368-0603 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO RAY VON FLUE <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: ElLyle D. Nimmo F-1Zane 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 gPTT.l . RTTCWU'r TFQTTN!_ l[Vrn]3N4 A-Vlr"XT <br />Test Method Used: ® Hydrostatic ❑ Wacuum ❑ Other <br />Test Equipment Used. TAPE H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I DIE <br />2 IE <br />3 <br />4 <br />cket Installation Type: <br />_ <br />LB <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />❑ contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />❑ Direct Bury <br />❑ Contained in <br />Sunp <br />cket Diameter:ucket <br />_ <br />Depth: <br />18 <br />18 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Ti): <br />1100 <br />1100 <br />eading (Ri): <br />17 1/2 <br />17 1/2 <br />Time (TF): <br />1200 <br />1200 <br />ading (RF): <br />17 1/2 <br />17 1/2 <br />ation (TF — Tj): <br />U <br />1 HOUR <br />1 HOUR <br />in Reading (RF - Ri): <br />0 <br />0 <br />l Threshold or00 <br />0 <br />0 <br />sult: <br />Z Pass ❑ Fail <br />®Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />%—uiuuients — (include irryormation on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOIA 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: 11-6-09 <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 />