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R <br /> n F V E D <br /> �ffftCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill co :T c Tm and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator f to e e tory agency. <br /> DEP <br /> 1. FACILITY INFORMATION <br /> Facility Name: ONE STOP 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(f present during testing): ELENA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°d 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 /> IA7777=77777'7 ncY-i e ALJ r %'ii <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ElContained in [:]Contained in <br /> ❑ Contained in Sump El Contained in Sump 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): 113 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: ® Pass ❑Fail ® Pass [:]Fail 0 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 />