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RjjC771VED <br />G ` SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />" !Jf�lQN� �" °TAL HEALTH <br />This form is intended for use by contractors performing annual testing of UST spikinme t�struF completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for su �dr`ta th` l regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ONE STOP I Date of Testing: 12-5-2016 <br />Facility Address: 1151 WEST LOUISE MANTECA CALIFORNIA 95336 <br />Facility Contact: HARI Phone: 209-823-4081 <br />Date Local Agency Was Notified of Testing :11-20-16 <br />Name of Local Agency Inspector (if present during testing): ELENA <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: ❑ Lyle D. Nimmo ❑ Zane 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 />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 1 87 2 91 3 DIE 4 <br />Number, Stored Product, etc. <br />® Direct Bury ®Direct Bury <br />® Direct Bury ❑ Direct Bury <br />Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in ❑ Contained in <br />Sump Sum <br />Bucket Diameter: 11 11 15 <br />Bucket Depth: 14 14 14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): 930 930 930 <br />Initial Reading (Ri): 13 13 13.50 <br />Test End Time (TF): 1030 1030 1030 <br />Final Reading (RF): 13 13 13.50 <br />Test Duration (TF — TI): 1 HOUR 1 HOUR 1 HOUR <br />Change in Reading (RF - RI): 0 0 0 <br />Pass/Fail Threshold or 0 0 0 0 <br />Criteria: <br />Test Result: Z Pass ❑ Fail ®: Pass 0 Fain Z Pass ❑ Fail ❑ Pass ❑ 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: _12-5-16 <br />' ate laws and regulations do not currently require testing to be performed by a qualified contractor. However, local <br />quirements may be more stringent. <br />