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0 <br /> 0 SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST.spill containment structures. The completed,JariPz and <br /> printouts ftonz tests (rf applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: GEORGE'S MINI MART Date of Testing: 5115112 <br /> Facility Address: 18662 N. HWY 88 LOCKEFORD, CA 95237 <br /> II <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/16/12 _ <br /> Name of Local Agency Inspector(fpresent during testing): ARIS CACAPIT _- <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 (2019) 744-0112 Fax: (209) 7,14-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo Z Zane A. Nimmo ❑ David A. Winkler El Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials`: Z ICC Service Tech. Z 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 /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ® Direct Bury Direct Bury— <br /> Bucket Installation Type: Z Direct Bury Z Direct Bury ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump <br /> Sump Sum <br /> -- <br /> Bucket Diameter, 11 I1 11 11 <br /> Bucket Depth: 14 13 13 1/2 14 - <br /> Wait time between applying _- -- -- <br /> vacuum/water and start of test: - <br /> Test Start Time(Ta): 0908 0908 0908 0908 <br /> Initial Reading(Rj): 13 5/8 12 114 12 518 13 1/2 <br /> Test End Time jr): 1008 1008 1008 1008 <br /> Final Reading(RF): 13 5/8 12 114 12 5/8 13 1/2 <br /> Test Duration(TF—T3): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 0 - <br /> Pass/Fail Threshold or <br /> Criteria: _ <br /> Test Result: Z Pass El Fail Z Pass ❑ Fail Pass ❑ Fail I ® Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-zip foi•failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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: <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 />