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0 0 <br /> 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.FACILITY INFORMATION <br /> Facility Name: COUNTY MART GAS&FOOD 76 1 Date of Testing: JUNE 17,2009 <br /> Facility Address: 34243 SOUTH CHRISMAN ROAD YRACY CALIFORNIA 95376 <br /> Facility Contact: I Phone: 209-832-8642 <br /> Date Local Agency Was Notified of Testing:05-20-09 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO GARRETT BACKUS <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 DIE <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ® Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: El Contained in F-1 Contained in <br /> El Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 13 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 900 900 <br /> Initial Reading(RI): 12 12 13 13 <br /> Test End Time(TF): 1000 1000 1000 1000 <br /> Final Reading(RF): 12 12 13 13 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result; Z Pass ❑Fail 0 ,Pass ❑Fail Pass' ❑Fail Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: <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 />