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DEC 2 9 ?i"CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This orm is intended or use b contractors I0 �MM 51 <br /> ./� f y performing annual testing of UST spill cont]! gtnaornres^T91eACdMp`leted form and <br /> printouts 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 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(ifpresent during testing): 11-25-15 <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: NEd Steams ❑Lyle D.Nimmo <br /> 5250492-UT El Zane A.Nimmo ❑ David A.Winkler El Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N 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, Stared Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury E]Direct Bury Direct Bury Lj Direct Bury <br /> El Contained in Sump ❑ E] Contained in El Contained in <br /> Contained in Sump Sump Sum <br /> Bucket Diameter: 1I <br /> Bucket Depth: 121/2 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 915 <br /> Initial Reading(Ri): 113/4 <br /> Test End Time(TF): 1015 <br /> Final Reading(RF): 113/4 <br /> Test Duration(TF—T,): 1HR <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or I/16 1/16 1/16 <br /> Criteria: <br /> Test Result: N Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (inchide information on repairs made prior to testing, and recommendedfollow-upforfailed 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] f-W 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 />