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to <br />REULNtu <br />0CTSpi7c1,j$anuary 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containmeERMAONMENWM � o tid <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to tlBpTMV*Tagency. <br />1. FACILITY INFORMATION <br />Facility Name: TOYS R US Date of Testing: 10-07-16 <br />Facility Address: 1624 ARMY CT STOCKTON CA <br />Facility Contact: GLEN Phone: 209-465-4912 <br />Date Local Agency Was Notified of Testing :09-22-16 <br />Name of Local Agency Inspector (rf present during testing): SAN JOAQUIN CO MICHELLE <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd 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 />II 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 / H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 DIESEL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct B <br />❑in Sump <br />❑ Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />[—] Contained in <br />Sump <br />❑ Direct Bury <br />El Contained inContained <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (TI): <br />900 <br />Initial Reading (Ry): <br />14 <br />Test End Time (TF): <br />1000 <br />Final Reading (RF): <br />14 <br />Test Duration (TF — TI): <br />1 HOUR <br />Change in Reading (RF - Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />❑ 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 />OPW BUCKET <br />BUCKET MEASURED OUT TO HOLD AT LEAST S GALLONS <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: 10-07-16 <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 />