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V <br />0 0 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />T his 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 />l � ► •).7l!�7�77 C��ii <br />Facility Name: STOCKTON GATE: WAY 76 Date of Testing: 8-13-2009 <br />Facility Address: 322 S CENTER ST STOCKTON CA <br />Facility Contact: RON Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector ('(present during testing): RAY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 II <br />3• SPIIJ, RTTCKF,T TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O & TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />E] Contained in <br />Sum <br />_ <br />Bucket Diameter: <br />1 1 <br />11 <br />Bucket Depth: <br />14 <br />15 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA <br />NA <br />NA <br />NA <br />Test Start Time (Ti): <br />900 <br />900 <br />Initial Reading (Rj): <br />13 <br />14 <br />Test End Time (TF): <br />1000 <br />1000 <br />Final Reading (RF): <br />13 <br />14 <br />Test Duration (TF — Ti): <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />E Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ 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: VlzJ—j <br />Date8-13-2009 <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 />