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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- FACIT.TTV INFORMATION <br />Facility Name: TOYS R US Date of Testing: 9-29-09 <br />Facility Address: 1624 ARMY CT STOCKTON CA <br />Facility Contact: I Phone: 209-465-4912 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f 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 11 <br />3. SPTT,T, RTIrKFT TFV%TTNf TNFnRMATTnN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O & TAPE MEASURE <br />I Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />l DSL <br />2 -- <br />3 <br />4 <br />Type* Bucket Installation T e: <br />®Direct Bury <br />E:1Contained in Sump <br />E] Direct Bury <br />E]Contained in Sump <br />El Direct Bury <br />ElContained in <br />Sump <br />❑ Direct Bury <br />❑Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />12 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA <br />Test Start Time (TI): <br />2PM <br />Initial Reading (Ri): <br />11 <br />Test End Time (TF): <br />3PM <br />Final Reading (RF): <br />11 <br />Test Duration (TF — Ti): <br />1 HR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />k-omments — (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 />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: T")— <br />Date 9-29-2009 <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 />