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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: GEMCO GAS & GROCERY Date of Testing: 3/6/2017 <br /> Facility Address: 1022 E. FRONTAGE RD. RIPON , CA 95366 <br /> Facility Contact: Gurprett I Phone: 59-21M ? a -� <br /> Date Local Agency Was Notified of Testing:1/30/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): ELENA I <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2""Street Galt,CA 95632 (2 44- 'Nt-0116 <br /> Technician Conducting Test: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 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 /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bu ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Bury Ll Bury ❑Contained in <br /> yP El Contained in Sum [0-1 Contained in <br /> Sump Contained in Sump Sum Sum <br /> Bucket Diameter: I 1 11 <br /> Bucket Depth: 13 3/4 14 7/8 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0926 0926 <br /> Initial Reading(Ri): 12 3/4 13 7/8 <br /> Test End Time(TF): 1026 1026 <br /> Final Reading(RF): 12 3/4 13 7/8 <br /> Test Duration(TF—T,): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-upforfailed 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 requirements. <br /> Technician's Signature Date:3-6-17 <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 />