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SWRCB, January 2006 <br />IIiIIII <br />ill <br />III,1 ' <br />i <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. FACILITY INFORMATION <br />Facility Name: QUICK SHOP 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: <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO CEASER <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler E Felix G. Ramirez <br />814188 8211269 5263373 -UT 5273934 -UT <br />I 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 />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 100 <br />2 110 3 DIESEL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />® Direct Bury El Contained in <br />El Contained in Sump Sump <br />E] Direct Bury <br />❑ Contained in <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 />- - <br />Test Start Time (Ti): <br />935 <br />935 935 <br />Initial Reading (R,): <br />12 <br />12 12 <br />Test End Time (TF): <br />1035 <br />1035 1035 <br />Final Reading (RF): <br />12 <br />12 11 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR 1 HOUR <br />Change in Reading (RF - RI): <br />10 <br />0 1 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />® Pass ❑ Fail <br />I S Pass ❑ Fail ❑ Pass ®'Fail <br />❑ Pass `r ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW BUCKETS <br />DIE SB FAILED <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 />