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IECEIVED <br /> N!�,y 0 9 S�I�Mt4CB,January 2006 <br /> Spill Bucket Testing Report Form /�p�A'�A <br /> This form is intended for use by contractors performing annual testing of UST spill contain Jtdtw/A3��i form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for sub � P �ry agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: VALLEY SERVICE STATION ARCO I Date of']esting: 02-27-14 <br /> Facility Address: 16 EAST HARDING WAY STOCKTON CALIFORNIA 95204 <br /> Facility Contact: MANNY Phone: 209-466-9516 <br /> Date Local Agency Was Notified of Testing:01-30-14 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO JEFF WONG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°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 E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identif� Spill Bucket (Bi junk 1 87 2 87 3 DIESEL 491 <br /> Number, Stored Product, etc.) <br /> El Direct Bury [I Direct Bury Direct Bury ❑Direct Bury <br /> Bucket Installation Type: E Contained in E Contained in <br /> E Contained in Sump E Contained in Sump SumpSum <br /> Bucket Diameter: 11 I 1 11 11 <br /> Bucket Depth: 14 14 11 12 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1030 1030 1045 1100 <br /> Initial Reading(111): 13 13 10 11 1/2 <br /> Test End Time(TF): 1130 1130 1145 1200 <br /> Final Reading(RF): 13 13 10 11 1/2 <br /> Test Duration(TF—Tt): 1 HOUR I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW SPILL BUCKETS. 87 IS A QUAD FILL SUMP <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all theinformationcontained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:02-27-14 <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 />