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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 form and <br /> printouts from tests(if 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: 5/15112 <br /> Facility Address: 18662 N. HWY 88 LOCKEFORD, CA 95237 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/16112 <br /> Name of Local Agency Inspector(if present during testing): ARIS CACAPIT <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Compam. Narne: AFFORDA TEST 4162"d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D,Nimmo 0 Zane A.Nimmo ❑ David A.Winkler ❑ 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 1 3 91 -7DIESEL <br /> IV'arrrther, Stored Product, etc.) <br /> ® Direct Bury ❑ Direct Bury ❑ Direct Bury Z Direct Bury <br /> Bucket Installation Type: ❑ Contained in <br /> ❑ Contained in Sump Contained in Sump El Contained in <br /> ❑ <br /> Sump Sump <br /> Bucket Diameter: 11 11 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(T,): 0908 0908 0908 0908 <br /> Initial Reading(111): 13 5/8 12 1/4 12 5/8 13 112 <br /> Test End Time(TF): 1008 1008 1008 1008 <br /> Final Reading(RF): 13 5/8 12 1/4 12 5/8 13 112 <br /> Test Duration(TF—Tj.- HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- -- -- <br /> Test Result: ®Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail Z Pass ❑ Fail <br /> Comments-- (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS'TESTING <br /> hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's SignatureDate: <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 />