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L] <br />U&4c13'15nuary 2006 <br />Spill Bucket Testing Report Form �m } <br />This form is intended for use by contractors performing annual testing of UST spill containment structures- Ai 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: SAN JOAQUIN MOTORPOOL Date of Testing: 7-27-2016 <br />Facility Address: 121 SAN JOAQUIN ST STOCKTON CA <br />Facility Contact: ROBERT Phone: 209-468-2068 <br />Date Local Agency Was Notified of Testing :6-30-16 <br />Name of Local Agency Inspector (f present during testing): ARIS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2°d 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 />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: TAPE / <br />H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury F] Direct Bury <br />E] Contained in Sump ❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />17 <br />Bucket Depth: <br />22 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1 <br />Initial Reading (RI): <br />21 <br />Test End Time (TF): <br />2 <br />Final Reading (RF): <br />21 <br />Test Duration (TF —Ti): <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail - <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <br />EXTRA LARGE BUCKET <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 />Te hnician's Signature:. Date:7-27-16 <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 />