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9EC <br />,January 2006 <br />Spill Bucket Testing Report Form AUG 2 2 <br />This form is intended for use by contractors performing annual testing of UST spill contain i(,iii .wructures. The cvr�pli&Lfff and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for sz mittal to the local regui ry agency. <br />1. FAC'II,ITV INFORMATION � <br />Facility Name: LOVES TRAVEL PLAZA Date of Testing: 08-08-17 <br />Facility Address: 1533 COLONY RD RIPON CA 95366 <br />Facility Contact: Jessie Phone: <br />Date Local Agency Was Notified of Testing :07-09-17 <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2' 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 />Credentials': ® ICC Service Tech. JZ SWRCB Tank Tester <br />3. SPTT.T, RIIC'KF.T TESTING: INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other' <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 DIESEL NORTH <br />2 DIESEL SOUTH <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury❑ <br />®Contained in Sump <br />Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1000 <br />1000 <br />Initial Reading (Ri): <br />13 <br />12 <br />Test End Time (TF): <br />1100 <br />1100 <br />Final Reading (RF): <br />13 <br />12 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <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 BUCKETS <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:08-08-17 <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 />