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n <br />IN <br />�� )� SWRCB, January 2006 <br />Spill Bucket Testing Report Forin <br />This form is intended for use by contractors performing annual testing of UST spill cor � nt tr cit ,res it pleted form and <br />printouts from tests (f applicable), should be provided to the facility owner/ope ii'r� N si bmaita�.t &hese al regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: QUICK SHOP I 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: 3-22-16 <br />Name of Local Agency Inspector (afpresent during testing): SAN JOAQUIN CO ELENA <br />Company Name: AFFORDA TEST 416 2nd 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 />11 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester (I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 100 <br />Number, Stored Product, etc) 7 <br />2 110 <br />3 DIESEL <br />4 <br />E Direct Bury <br />Bucket Installation Type: <br />El Contained in Sump <br />E Direct Bury <br />F-1 Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />F-1DirectBury <br />F-1Containedin <br />Sum <br />Bucket Diameter: 11 <br />l 1 <br />11 <br />Bucket Depth: 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 />Initial Reading (Ri): <br />12 <br />12 <br />Test End Time (TF): <br />1035 <br />1035 <br />Final Reading (RF): <br />12 <br />7 <br />Test Duration (TF — Tj): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />5 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ❑ Fait <br />® <br />Pass ❑ Fail <br />❑ Pass ®fail <br />❑ Pass ❑' Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <br />100 BUCKET NOT TESTED. NO REPAIRS FROM LAST FAILED TEST <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:03-22-1 <br />g 6 <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 />