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0 0 <br />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: MIRAMIR ENT. I Date of Testing: 05-27-15 <br />Facility Address: 1605 S ELDORADO ST STOCKTON CA <br />Facility Contact: ANGLE <br />Phone: 209-939-1906 <br />Date Local Agency Was Notified of Testing :4-23-15 jUN <br />18 20i.9 <br />Name of Local Agency Inspector (f present during testing): STACY <br />Company Name: AFFORDA TEST 4162 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 />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BTJCKF.T TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 <br />.,, <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />..3 <br />1 87 <br />2 91 <br />....:.. ; .... <br />77,777""', .;,.: <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />E] Contained in Sump <br />❑ Direct Bury <br />El Contained in <br />Sump <br />El Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />9 <br />9 <br />Initial Reading (Ri): <br />13 <br />13 <br />Test End Time (TF): <br />10 <br />10 <br />Final Reading (RF): <br />13 <br />13 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - R,): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result. <br />JZ'Pass ❑ <br />Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ FaiI <br />❑ Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW BUCKETS <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 />T 'hnician's Signature:. Date:05-27-15 <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 />