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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 o T <br />Is <br />Facility Address: 14971 N HWY 88 LODI CA <br />Facility Contact: Rupi Phone: APR 0 6 2615 <br />Date Local Agency Was Notified of Testing :2-26-15 <br />Name of Local Agency Inspector (f present during testing): Aris inmAKIRACKLTAI <br />2. TESTING CONTRACTOR INFORMATION`a�®`tee AAS T <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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester d <br />'A CPII.i. RITC'KF.T TFC'TINC. INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: <br />1/16 <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />El Contained in <br />SUMP <br />El Direct Bury <br />F-1Containedin <br />Sum <br />Bucket Diameter: <br />I 1 <br />11 <br />11 <br />Bucket Depth: <br />11 <br />11.50 <br />11.50 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />12 <br />12 <br />12 <br />Initial Reading (Rj): <br />10 <br />11 <br />11 <br />Test End Time (TF): <br />l <br />1 <br />1 <br />Final Reading (RF): <br />10 <br />11 <br />11 <br />Test Duration (TF — Tj): <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />Z Pass `<❑ Fail <br />Z Pass ❑ Fail <br />® Pass El Fail <br />Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up jor jailed tests) <br />opw flappers <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: <br />Date 3-31-15 <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 />