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RECEIVED <br />A�R�� 3�e��t�ry 2006 <br />Spill Bucket Testing Report Form L4 <br />This form is intended for use by contractors performing annual testing of UST spill containment ROMME ty7 l Afc-H <br />printouts from tests (tf applicable), should be provided to the facility owner/operator for submittal to the lfji#rrw,cgercy. <br />1. FACILITY INFORMATION <br />Facility Name: LOVES TRAVEL PLAZA Date of Testing: 08-12-14 <br />Facility Address: 1533 COLONY RD RIPON CA 95366 <br />Facility Contact: KEVIN Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): ELAINA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 "d 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 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O I <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By lank <br />Number, Stored Product, etc.) <br />1 DIESEL NORTH <br />2 DIESEL SOUTH <br />3 <br />4 <br />Bucket Installation Type: <br />[:1 Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: <br />I I <br />l 1 <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 />1045 <br />1 135 <br />Initial Reading (Rt): <br />13 <br />12 <br />Test End Time (TF): <br />1100 <br />1235 <br />Final Reading (RF): <br />10 <br />12 <br />Test Duration (TF — Tt): <br />15 MIN <br />1 HOUR <br />Change in Reading (RF -Rt): <br />3 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ® Fail <br />E 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 />Diesel north to be reamired & retested by others. <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:08-12-14 <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 />