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S WRCB;'J 006 <br /> Spill Bucket Testing Report Form MAR 1 20"3 <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(if applicable), should be provided to the facility owner/operator for submittal to tW1WR`regu1d$k ncy. <br /> 1. FACILITY INFORMATION <br /> -,T'%''7NT <br /> Facility Name: VALLEY SERVICE STATION ARCO Date of Testing: 2-28-2018 <br /> Facility Address: 16 E HARDING WAY STOCKTON,CA 95204 <br /> Facility Contact: Phone: 209-466-9516 <br /> Date Local Agency Was Notified of Testing: 1/30/18&2/20/18 <br /> Name of Local Agency Inspector(f present during testing): STACY SJV <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: ❑Ed Stearns ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-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 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank l 87 2 87 3 91 4 DIE <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in ® Contained in <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 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): 9 9 9 9 <br /> Initial Reading(Ri): 13 13 10 11 1/2 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(RF): 13 13 10 11 1/2 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: ® Pass ❑ 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 /> OPW SPILL BUCKETS. 87 IS A QUAD FILL SUMP <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:W <br /> Date:2-28-2018 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local <br /> requirements may be more stringent. <br />