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E V E D <br /> Spill Bucket Testing Report Form <br /> MAYAwl ,January 2006 <br /> This form is intended for use by contractors performing annual testing of US7'spill containment s1eN"S4DWE A11ed form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submit���R,ihe;lgc �fITrgency. <br /> tit <br /> 1. FACILITY INFORMATION <br /> Facility Name: VAN DE POL - PACIFIC PRIDE Date of Testing: 5/14/2018 <br /> Facility Address: 816 S. FRONTAGE ROAD RIPON , CA 95336 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:RETEST <br /> Name of Local Agency Inspector(f present during testing): NO SHOW <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8883080—UT 8883064-UT 8883059-UT 8883072-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 r7— 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in ® Contained in <br /> ®Contained in Sump ❑Contained in Sump sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 14 1/2 13 1/2 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 0913 0913 0913 <br /> Initial Reading(R,): 13 1/2 13 1/2 12 - <br /> Test End Time(TF): 1013 1013 1013 <br /> Final Reading(RF): 13 1/2 13 1/2 12 - <br /> Test Duration(TF—T,): HOUR HR HR <br /> Change in Reading(RF-R,): 0 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 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 full compliance with legal requirements. <br /> Technician's Signature: Date: 5/14/2018 <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 />