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• RECEIVE® <br /> SEP 2 7 201f;WRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spilhj �Y}s�l�)7efd form and <br /> printoutsom tests(fapplicable), should be provided to the facility owner/opera'oor jor s <br /> frub"OrtMeWegulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: EMIL'S LIQUOR& SPORT SHOP Date of Testing: 6/28/2016 <br /> Facility Address: 1405 CALFORNIA ST, ESCALON, CA 95320 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:6/23/2016 <br /> Name of Local Agency Inspector(ifpresent during testing): ARTS <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. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑vacuum ❑Other <br /> Test Equipment Used: I'AI'EME.ASURE, 1120 Equipment Resolution: Ii16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury El Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: El in El Contained in <br /> E] Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 12 3/4 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0930 0930 0930 <br /> Initial Reading(Rt): 11 3/4 12-- 13 - <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 11 3/4 12-- 12 3/4 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 1 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 /> ALL BUCKETS MEASURED 5 GALLONS <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:-6-28-16 <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 />