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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 /> 1. FACILITY INFORMATION <br /> Facility Name: LOVES TRUCK CENTER Date of Testing: 8-15-12 <br /> Facility Address: 1533 COLONY RD. RIPON, CA 95366 <br /> Facility Contact: KIM&KEVIN Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(ifpresew churing tesling): MUNI & STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"' Street Galt,CA 95632 (209)744-0112 Fax:(209) 744-01 16 <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 1: ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, 1-120 Equipment Resolution: 1/16" <br /> Identify Spill Bucket(131' Tank 1 DIESEL TI 2 DIESEL T2 3 4 <br /> Numher, Slored Produrl, etc'.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: E]Contained in Ll Contained in <br /> ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 1 I 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 <br /> Initial Reading(Rj): 13 12 1/2 <br /> Test End Time(TF): 10 10 <br /> Final Reading(RF): 8 12 1/2 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF- Ri): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: FAIL ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> To be repaired and retested <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: 8-15-12 <br /> , �_j <br />