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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printottts 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: GRUPE AIR I Date of Testing: 12-6-2013 <br /> Facility Address: 5000 S LINDBERGH ST STOCKTON CA <br /> Facility Contact: MAURICE Phone: <br /> Date Local Agency Was Notified of Testing:11-11-13 <br /> Name of Local Agency Inspector(if present during testing): Muni <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: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: H2O&TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 JET FUEL 4 <br /> Number;Stored Product,etc.) <br /> [9 Direct Bury ❑Direct Bury <br /> Bucket Installation Type: E]Contained in <br /> ❑Contained in Sump Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12.50 <br /> Wait time between applying NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 910 <br /> Initial Reading(RI): 12 <br /> Test End Time(TF): 1010 <br /> Final Reading(RF): 12 <br /> Test Duration(TF—Tr): 1 HR <br /> Change in Reading(RF-Rt): 0 ENVIR®NMNTA .. HEALTH <br /> Pass/Fail Threshold or 1/16 DEPA, TRENT <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail I ❑ Pass ❑Fail <br /> COMMCIItS—(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: V-6-j Date 12-6-2013 <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 />