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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. FACILITY INFORMATION <br /> Facility Name: COUNTRYSIDE MINI MART Date of Testing: 4-25-2011 <br /> Facility Address: 14971 N HWY 88 LODI CA <br /> Facility Contact: EDDIE Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRET <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 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: h20 and tape measure Equipment Resolution: 1/16 <br /> la. ... .. .. .i�hS� .%+t �"a1'14Ji 4 73�`mN._.'*m7, <br /> Identify Spill Bucket(By Tank =118=77 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: E]Contained in El Contained in <br /> F-1Containedin Sump E]Contained in Sump <br /> Sum Sum <br /> Bucket Diameter: I 11 11 11 <br /> Bucket Depth: 11 11.50 11.50 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12 12 12 <br /> Initial Reading(RI): 10 11 11 <br /> Test End Time(TF): 13 13 13 <br /> Final Reading(RF): 10 11 11 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: Pass ❑Fail 0 Pass ❑Fail Z 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 4-25-2011 <br /> i 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 />