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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 />l��I:��]IrlY11i1►1�C1 ; u : 1 <br />Facility Name: TOYS R US Date of Testing: 10/9/2015 <br />Facility Address: 1624 ARMY COURT STOCKTON , CA <br />Equipment Resolution: 1/16" <br />Facility Contact: TONY Phone: <br />Date Local Agency Was Notified of Testing :9/22/2015 <br />Name of Local Agency Inspector (f present during testing: STACY AND VICKY <br />7 TFQrF N!_ lYlNT7?APrr"12 INV"]?XiATinN ENVIRONMENTAL <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 E Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />II Credentials': E ICC Service Tech. E SWRCB Tank Tester 1I <br />3. SPILL Bi1CKF.T TESTING INFORMATION <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (4v Tank <br />Number, Stored Product, etc.) <br />1 <br />2 <br />3 <br />4 DIESEL <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />El Contained in <br />Sump <br />E 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 />1130 <br />Initial Reading (Ri): <br />11 - <br />Test End Time (TF): <br />1230 <br />Final Reading (RF): <br />11 - <br />Test Duration (TF— Ti): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF- R[): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ❑ Fail <br />❑ Pass []Fail <br />❑ Pass ❑ Fail <br />E 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 751� �'`-��"- Date: 10-9-15 <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 />