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06 / 28 / 2019 19 : 29 887674 Elvl = PAGE 26 <br /> SWRCB , January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors Per annual testing of UST spill containment structures. The completed form and <br /> p'intotuts from tests (if applicable), should be provided to the facility ownerioperatorfor submittal to the local regulatory agency. <br /> I . FACILITX INFORMATION <br /> I . <br /> Facility Name; E✓MILS LIQUOR & SPORTS SHOP Date of Testing : 6/27/ 13 <br /> Facility Address : 1405 CALIFORNIA ST , ESCALON , CA 953201 <br /> Facility Contact; CHACKO Phone: <br /> Date Local Agency Was Notified of Testing :5 /21 / 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) 7.44-0112 Fax : (209 ) 744-0116 <br /> TCCI) nician Conducting Test: Ed Steams ❑ Zane A. Nimrno ❑ David A. Winkler r] Felix G. Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials : � ICG Service 'I'ech . � SWlZCt3 TankTestcr <br /> . 3 . SPILT. BUCKET 'TESTING INFORMATION <br /> ❑ Other <br /> Test Method Used : [� 1lydcostatic C] Vacuum <br /> Test Equipment Used : TAPE MEASURE Equipment Resolution; 1 / 16 <br /> ldentif Spill Bucket (By Wank 1 87 �r 2 91 3 DSL 4 <br /> .Nttmber, Stored Product. e1c. ) 1:111111 <br /> ® Direct Bury ❑ Direct Buy <br /> Direct l3uty Direct Bury Contained in F] Contained in, <br /> Bucket Installation Type : El Contained in Sump Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth : 13 3/4 13 14 <br /> Wait time between applying -- <br /> vacuum/water and start of test: <br /> Test Start Time (Ti): 0900 0900 0900 <br /> initial Reading (Rt) : 12 12 13 <br /> Test End Time (TF) : 1000 1000 1000 <br /> Final heading (RF) : 12 12 13 <br /> Test Duration (Tr — TI) : 1HR l HR 111R <br /> Change in Reoding (RF � R• t) = 0 0 0 <br /> Pass/Fail Threshold or 1/16 1 / 16 1 / 16 <br /> Criteria : <br /> Test Result: : 0 . Pass . `` ( ::lH`aitlass Fail <br /> ' Pass Fall . <br /> Fail � . P ( <br /> Comments — include informations on repairs made prior to testing.. and recommended ollow-u or ailed tests <br /> 7t1C el 'ai e CO not OCate ea Tee s contractor to replace or repair then retest . <br /> e5e Spll <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS USTING <br /> I hereby eertify that all the information contained in this report is true, accurate, and ita full colttplianee with legal rcquirerneltts. <br /> Teehnlcian ' s Signature Date-: 6/27/ 18 <br /> State lags and regulations do not currently require testing to be performed by a qualified contractor, however, local requirements <br /> mai' be more stringent . <br /> Received Time � Jun , 28 . 2019 7 : 27PM No , 5223 - <br />