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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: GRUPE COMMERCIAL I Date of Testing: 12/20/2016 <br /> Facility Address: 5000 S. LINDBERGH STOCKTON,CA 95267 <br /> Facility Contact: MAURICE Phone: 209-473-6204 <br /> Date Local Agency Was Notified of Testing:11/20/2016 <br /> Name of Local Agency Inspector(f present during testing): VICKI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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': N ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 JET FUEL 2 3 4 <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ❑Direct Bury El Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑ Contained in E] Contained in <br /> El Contained in Sump E]Contained in Sump Sump Sump <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12 3/4 <br /> Wait time between applying _- - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0900 <br /> Initial Reading(Ri): 12 1/8 <br /> Test End Time(TF): 1000 <br /> Final Reading(RF): 12 1/8 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ; ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> MEN <br /> JAN 1 82012 <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 co Ire l <br /> Technician's Signature ;>_ Date: 12-20-16 DEPARTMENT <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 />