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• 0 SWRCB, January 2006 <br />0 <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 FACII.ITV INFnRMATION <br />Facility Name: MIRAMIR ENT. Date of Testing: 5-9-16 <br />Facility Address: 1605 S EL DORADO ST STOCKTON CA ti <br />Facility Contact: ANGLE Phone: 209-939-1906" <br />Date Local Agency Was Notified of Testing A-22-16 <br />Name of Local Agency Inspector (fpresent during testing): STACY b216 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209)''/44-a116� <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 />d Credentials 1: ® ICC Service Tech. ® SWRCB Tank'Tester 1i <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 <br />Bucket Installation Type: <br />®Direct Bury <br />F-1Containedin Sump <br />®Direct Bury <br />E] Contained in Sump <br />E] Direct Bury <br />E] 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 />_ <br />Test Start Time (Ti): <br />10 <br />10 <br />Initial Reading (R,): <br />14 <br />14 <br />Test End Time (TF): <br />11 <br />11 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />- <br />_ <br />Test Result: <br />0 Pass ❑ Fail <br />0 <br />Pass" ❑ Fail <br />❑ Pass El 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 />hnician's Signature:. Dat5-9-16 <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 />