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', <br />T9, <br />R E 1�1 Janus X006 <br />ry <br />Spill Bucket Testing Report Form MAR 10 2017 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures.. The cgouLoC7�mjgptletedafoorm and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal <br />NVIRON M t I Hi <br />1. FACILITY INFORMATION r rr A r1T11 ArAIT <br />Facility Name: HARDY'S GAS & FOOD <br />I Date of Testing:-- 2/21/2017 <br />Facility Address: 16 E. HARDING WAY <br />STOCKTON , CA 95204 <br />Facility Contact: HARDEEP <br />Phone: 466-9516 <br />Date Local Agency Was Notified of Testing :1/30/2017 <br />2 87 - WEST <br />Name of Local Agency Inspector (if present during testing): <br />STACY RIVERA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd 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. SPIM, BUCKET TFSTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 - EAST <br />2 87 - WEST <br />3 91 <br />4 DIESEL <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 />SumpSum <br />❑ Direct Bury <br />® Contained in <br />Bucket Diameter: <br />1 I <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 1/4 <br />14 1/4 <br />13 1/4 <br />11 1/8 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1000 <br />1000 <br />1000 <br />1000 <br />Initial Reading (RI): <br />11 1/2 <br />11 1/2 <br />11 1/2 <br />11 1/8 <br />Test End Time (TF): <br />1100 <br />1100 <br />1100 <br />1100 <br />Final Reading (RF): <br />11 1/2 <br />11 1/2 <br />11 -- <br />11 1/8 <br />Test Duration (TF — TI): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF -RI): <br />0 <br />0 <br />-1/2 <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 />91 Spill bucket failed at bottom. To be repaired and 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: 2-21-17 <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 />