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' �Sp111 I3ueket Testing Report For�,n SWRCB„January 2006 <br /> Thisforin is intended for use by contractors performing annual testing of UST spill containment structures. The completed farm an <br /> printouts from tests (if applicable), should be provided to the facility oivnerloperator far submittal to the local regulatory agencjj. <br /> I. FACILITY INFORMATION _ <br /> Facility Name: GEORGE'S MINI MART Date of Testing: 5/11/10 v <br /> Facility Address: 18662 N. HWY 88 LOCKEFORD,CA 95237 <br /> Facility Contact: I Phone: 209-727-3064 <br /> Date Local Agency Was Notified of Testing :4/6/10 — _ _- <br /> Name of Local Agency Inspector(rfpresent during testing): ARIS CACAPIT -_ <br /> 2. TESTING CONTRACTOR INFORMATION T <br /> Company Name: AFFORDA TEST 416 2'r6 Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D. Nimmo Z Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez_ <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION ll <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other __ _ <br /> Test Equipment Used: TAPE MEASURE, 1-120 Equipment Resolution: 1/16" <br /> Identify Spill Bucket (hy Tank 1 87 OCT 2 59 OCT 3 91 OCT 4 DIESEL 2 - <br /> Number, Stored Product, etc.) <br /> Direct Bury ® Direct Bury ❑ Direct Bury ❑ Direct Bony <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SumpSum_ <br /> Bucket Diameter: l l 1 1 1 1 1 1 <br /> Bucket Depth: 14 13 13 14 -- <br /> Wait time between applying <br /> vacuum/water and start of test: --- <br /> Test Start Time(Ti): 1000 1000 1000 1000 <br /> Initial Reading(Rt): 125/8 11 518 12 13 - <br /> Test End Time(TF): 1100 1 100 1100 1100 <br /> Final Reading(RF): 12 5/8 1 1 5/8 12 13 - <br /> Test Duration(TF-Ti): HR HR HR HR <br /> Change in Reading(RF-Rt): 0 0 0 a —_ --- -_- <br /> Pass/Fail Threshold or -- <br /> Criteria: <br /> Test Result: 2 Pass ❑ Fail ❑ Pass [:] Fail ® Pass ❑ Fail Pass ❑ Fail- <br /> Comments - (include information on repairs made prior to testing, and recor,zrraended follovv-atp 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 full compliance with legal requir-emernts. <br /> 'T'echnician's Signature: �� Date: 5-1 1-10 <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 />