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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 form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 F A CTT .TTV TNF(1RM A TInN <br />Facility Name: QUICK SHOP I Date of Testing: 09-19-17 <br />Facility Address: 2072 W YOSEMITE MANTECA CA <br />Facility Contact: PETE Phone: 209-824-6700 <br />Date Local Agency Was Notified of Testing: 8-24-17 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO CEASER <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: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />8184188 8211269 5263373 -UT 5273934 -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 / H2O Equipment Resolution: 1/16 <br />MMOMPROM <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 87 3 91 <br />4 <br />Bucket Installation Type:❑ <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury ® Direct Bury <br />Contained in <br />El Contained in Sump Sump <br />❑ Direct Bury <br />F-1Containedin <br />Sum <br />Bucket Diameter: <br />11 <br />11 11 <br />Bucket Depth: <br />13 <br />13 13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />935 <br />935 935 <br />Initial Reading (Ri): <br />12 <br />12 12 <br />Test End Time (TF): <br />1035 <br />1035 1035 <br />Final Reading (RF): <br />12 <br />12 12 <br />Test Duration (TF — Ti): <br />1 HOUR <br />i HOUR 1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />- <br />Test Result: <br />Z Pass [:]Fail <br />®`> Pass El Fail ® Pass ❑ Fail <br />❑ Pass ❑ FaiI ' <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW 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:09-19-17 <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 />