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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 owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: GEORGES MINI MART I Date of Testing: 5-19-2011 <br /> Facility Address: 18662 N HWY 88 LOCKFORD CA <br /> Facility Contact: RUPI Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(irpresent during testing): ARIS <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo Z David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: H ICC Service Tech. ® SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1116 <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 DSL <br /> Number, Stared Product, etc.) <br /> ® Direct Bury ®Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: El Contained in <br /> El Contained in Sump ❑Contained in Sump ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: l i 11 11 11 <br /> Bucket Depth: 14 13 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12 12 12 12 <br /> Initial Reading(RI): 13 12 12 13 <br /> Test End Time(TF): 1 I 1 I <br /> Final Reading(RF): 13 12 12 13 <br /> Test Duration(TF—T[): l HR 1 H R 1 HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or 1116 1/16 1116 1116 <br /> Criteria: <br /> Test Result: ❑ Pass ❑ Fail Z Pass ❑ Fail ® Pass ❑ Fail ® 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 /> I hereby certify that all the information contained in this report is true,accurate,and in fuA compliance with legal requirements. <br /> Technician's Signature: V-C�--j Date 5-19-2011 <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 />