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REGLIVED YS tnuary 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment rm and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal Vto the local regulatory agency. 1. FACILITY INFORMATION 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2,,d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other Facility Name: MIRAMIR ENT. I Date of Testing: 5-9-16 H2O Facility Address: 1605 S EL DORADO ST STOCKTON CA i€u.J.. iw...'»^' •r .C;, .t.'NY=✓.FSJa' Facility Contact: ANGLE Phone: 209-939-1906 Date Local Agency Was Notified of Testing A-22-16 Identify Spill Bucket (By Tank Number, Stored Product, etc. Name of Local Agency Inspector (ifpresent during testing): STACY 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2,,d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 i€u.J.. iw...'»^' •r .C;, .t.'NY=✓.FSJa' Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 91 3 4 Bucket Installation Type: ® Direct Bury El Contained in Sump ® Direct Bury ❑Contained in Sump ❑ Direct Bury ❑ Direct Bury EI Contained in El Contained in Sump Sum Bucket Diameter: 11 11 Bucket Depth: 14 14 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 10 10 Initial Reading (Rj): 14 14 Test End Time (TF): 11 11 Final Reading (RF): 14 14 Test Duration (TF — Ti): 1 HOUR 1 HOUR Change in Reading (RF - Ri): 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fain ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) OPW BUCKETS CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. W hnician's Signature:. Dat5-9-16 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.