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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors per forming annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to thefacility owrter/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: GRUPE AIR I Date of Testing: 12/18/15 <br /> Facility Address: 5000 S LINDBERGH STOCKTON,CA <br /> Facility Contact: MAURICE Phone: <br /> Date Local Agency Was Notified of Testing:11/25/15 <br /> Name of Local Agency Inspector(fpresent during testing): 11-25-15 <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°a Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician: MEd Steams ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-UT 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: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 JET-A 2 3 4 <br /> Number,Stored Product,etc. <br /> ®Direct Bury ❑Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in El Contained in <br /> ❑Contained in Sump ❑Contained in Sump SUMP Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 121/2 <br /> Wait time between applying <br /> vacuum/water and start of test: R F <br /> Test Start Time(TI): 915 <br /> Initial Reading(Ri): 113/4 i i ti a 2016 <br /> Test End Time(TF): 1015 <br /> Final Reading(RF): 113/4 <br /> Test Duration(TF—Tr): 1HR ENVIReNMENTAL HEALTH <br /> Change in Reading o E-g g(RF-Rj}: 0 <br /> NT <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: 0 Pass `❑Fail ❑ Pass ` ❑Fail ❑ Pass ` ❑Fall ❑ 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: :!fes=1 Date:12/18/15 <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 /> r <br />