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K <br />G_ $WRCB, January 2006 <br />Spill Bucket Testing Report Form ! <br />This form is intended for use by contractors performing annual testing of UST spill containhform and <br />printouts from tests (f applicable), should be provided to the facility owner/operator me r eo <br />c 7-" <br />ry agency. <br />1. FACILITY INFORMATION <br />Facility Name: PACIFIC CAR WASH Date of Testing: 5/8/2017 <br />Facility Address: 4405 PACIFIC AVE. STOCKTON, CA 95207 <br />Facility Contact: TAMMI Phone: <br />Date Local Agency Was Notified of Testing :4/20/2017 <br />Name of Local Agency Inspector (f present during testing): VICKY <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: ❑ Ed Stearns ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />8184188 5263322 -UT 5263373 -UT 5273934 -UT <br />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 <br />3 91 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 5/8 <br />15 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1000 <br />1000 <br />Initial Reading (Rj): <br />14 <br />14 <br />Test End Time (TF): <br />1100 <br />1100 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF — Ti): <br />HR <br />HR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />[�S�Pass <br />❑ <br />Fail <br />❑ <br />Pass <br />❑ <br />Fail <br />® <br />Pass <br />❑ Fail <br />❑ Pass ❑ <br />Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed 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 Date: _5-8-17 <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 />