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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CITY OF STOCKTON --CORP YARD I Date of Testing: 3/10/10 <br />Facility Address: 1465 S. LINCOLN ST. STOCKTON, CA 95206 <br />Facility Contact: TERRY WILLIAMS Phone: <br />Date Local Agency Was Notified of Testing :3/4/11 <br />Name of Local Agency Inspector (if present during testing): STACY <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: <br />® Hydrostatic <br />❑ Vacuum <br />El Other <br />Test Equipment Used: TAPE MEASURE, <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type:❑ <br />H2O <br />1 87 <br />® Direct Bury <br />F-1 Contained in Sump <br />2 <br />El Direct Bury <br />El Contained in Sump <br />Equipment Resolution: <br />3 <br />Direct Bury <br />Contained in <br />Sump <br />1/16" <br />4 DIESEL <br />Z Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 3/8 <br />16 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />1340 <br />1340 <br />Initial Reading (Ri): <br />13 3/8 <br />15 3/4 <br />Test End Time (TF): <br />1440 <br />1440 <br />Final Reading (RF): <br />13 3/8 <br />15 3/4 <br />Test Duration (TF — TI): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result:_ <br />Pass Fail- <br />❑ P.ass ❑Fail <br />❑ Pass ! ❑ Fail <br />Pass] Fail <br />Comments — (include in 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: e EE3 "_ 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 />