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ED <br />R F SWRCB, January 2006 <br />Spill Bucket Testing Report Form`'1 2 3 2017 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The co 1 ted form and <br />printouts from tests (f applicable), should be provided to the facility owner/operatpr��tltR��=ry agency. <br />1. FACILITY INFORMATION C'" `r nF.PARTMENT <br />Facility Name: TOYS R US I Date of Testing: 10/13/2017 <br />Facility Address: 1624 ARMY COURT STOCKTON , CA 95206 <br />Facility Contact: TONY Phone: 209465-4912 <br />Date Local Agency Was Notified of Testing :9/27/2017 <br />Name of Local Agency Inspector (f present during testing): CESAR <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 211 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 />8184188 8211269 5263373 -UT 5273934 -UT <br />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester n <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 <br />2 <br />3 <br />4 DIESEL <br />Bucket Installation Type: <br />F-1 Direct Bury <br />❑Contained in Sump <br />El Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />[—] Contained in <br />Sum <br />® Direct Bury <br />El 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 />Test Start Time (Ti): <br />0858 <br />Initial Reading (RI): <br />11 - <br />1 - <br />Test <br />Test End Time (TF): <br />0958 <br />Final Reading (RF): <br />11 - <br />Test Duration (TF — Ti): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />I ® 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 Date: 10-13-17 <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 />