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• 09ECEIVED <br /> S W RCB,January 2006 <br /> Spill Bucket Testing Report Form SEP 2 9 2016 <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The compl t r nd <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for sub?EUYf Dtd <br /> 1.FACILITY INFORMATION DEPARTMENT <br /> Facility Name: EMIL'S LIQUOR 8c 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 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 ❑ 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: TAPE MEASURE, H2O Equipment Resolution 1/16" <br /> Iduuik Spill Bucket(41� Tank 1 87 2 3 91 4 DIESEL <br /> Aumber, Stored Product, etc.) <br /> ® Direct Bury ❑Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: ❑ [:]Contained in ❑ Contained in Contained in Sump ❑ Contained in Sump <br /> SUMD Sum <br /> Bucket Diameter: 11 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(Ri): 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 0 <br /> Pass/Fail Threshold or — <br /> Criteria: LZ <br /> -- -- -- <br /> Test Result: Pass ❑Fait ❑ Psss ❑Fail M 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 />