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$Mf CB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill con #te�Tge c edrm and <br />printouts from tests (f applicable), should be provided to the facility owner/operator fo u mitts ZEN Q rg story agency. <br />1. FACILITY INFORMATION <br />Facility Name: QUICK SHOP Date of Testing: 03-22-16 <br />Facility Address: 2072 W YOSEMITE MANTECA CA <br />Facility Contact: PETE Phone: 209-824-6700 <br />Date Local Agency Was Notified of Testing :3-21-16 <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO ELANA <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 />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL RIJCKF.T TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / <br />H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, <br />1 87 <br />2 87 <br />3 91 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />F-1 Contained in <br />Sump <br />Bucket Diameter: <br />1 l <br />I 1 <br />11 <br />Bucket Depth. <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />935 <br />935 <br />935 <br />Initial Reading (RI): <br />12 <br />12 <br />12 <br />Test End Time (TF): <br />1035 <br />1035 <br />1035 <br />Final Reading (RF): <br />12 <br />12 <br />12 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result; <br />Z Pass ❑ Fail <br />® <br />Pass <br />❑ <br />Fail <br />[D <br />Pass ❑ Fait <br />❑ <br />Pass <br />❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <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:03-22-16 <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 />