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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: SRH FOOD&GAS Date of Testing: 5/25/18 <br /> Facility Address: 749 E CHARTER WAY STOCKTON,CA 95206 <br /> Facility Contact: JOHNNIE Phone: <br /> Date Local Agency Was Notified of Testing:4/25/18 <br /> Name of Local Agency Inspector(if present during testing): <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 /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By lank 1 87 2 91 3 DSL <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury <br /> ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ElContained in ❑Contained in <br /> ❑ Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I 1 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: ED <br /> Test Start Time(Ti): 930 930 930 <br /> Initial Reading(Rj): 12 12 12 7 ❑1d <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 12 12 12 =�INIMQNMi=NTAL <br /> Test Duration(TF—T,): IHR IHR IHR 0PAITH G`FPARI MEN <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail Z Pass ❑Fail ❑ 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: �`f" _%v Date:5/25/18 <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 />