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. 9 <br />4-,1 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 (f 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: <br />Facility Address: 14971 N HWY 88 LODI CA <br />Facility Contact: Rupi Phone: <br />Date Local Agency Was Notified of Testing :2-26-15 APR 08 2015 <br />Name of Local Agency Inspector (fpresent during testing): Aris 11 <br />L-imvinui,yjvjr_N IAL <br />2. TESTING CONTRACTOR INFORMATION "tea"TU MnrAw®,-r <br />Company Name: AFFORDA TEST 416 2°a 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. ® SWRC13 Tank Tester <br />3. SPIT,I, RIJCKF,T TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 DSL 4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />® Direct Bury ❑ Direct Bury <br />❑ Contained in ❑ Contained in <br />Sum Sum <br />Bucket Diameter: <br />11 <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 (RI): <br />10 <br />11 <br />11 <br />Test End Time (TF): <br />1 <br />1 <br />1 <br />Final Reading (RF): <br />10 <br />11 <br />11 <br />Test Duration (TF— TI): <br />IHR <br />IHR <br />1 HR <br />Change in Reading (RF- Rj): <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 />® Pass <br />E) Fail <br />® <br />Pass <br />❑ Fail <br />0 Pass ❑ )Fail ❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />onw 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: T��—j <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 />