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.w RECEIVEF) <br /> FEB s0v6Mlddanaary 2006 <br /> Spill Bucket Testing Report Form t__A'� (� T <br /> This form is intended for use by contractors performing annual testing of UST spill containment.tlxkikllrllc!SPh� d, o�m and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to ih2!'oral regu atory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: RIVER POINT LANDING Date of Testing: 1/21/2015 <br /> Facility Address: 4950 BUCKLEY COVE WAY STOCKTON, CA 95219 <br /> Facility Contact: ANDREW Phone: 209-951-4144 <br /> Date Local Agency Was Notified of Testing:12/22/14 <br /> Name of Local Agency Inspector(ifpresent during testing,): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo N Zane A.Nimmo ❑ David A.Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identity Spill Bucket(By TauA 1 89 2 RED DIESEL 3 4 <br /> Number, Stored Product, etc. <br /> N Direct Bury N Direct Bury Ej Direct Bury Direct Bury <br /> Bucket Installation Type: El Contained in EI Contained in <br /> ❑Contained in Sump ElContained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 1/2 12 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1330 1330 <br /> Initial Reading(R,): 13 1/2 11 1/2 <br /> Test End Time(TP): 1430 1430 <br /> Final Reading(Rr): 13 1/2 11 1/2 <br /> Test Duration(Tr—T,): HR HR <br /> Change in Reading(Rr-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑ Fail N 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 /> 1 hereby certify that all the information <br /> nfcontained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: C/ `-`_ Date:_1-21-15 <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 />