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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 ownertoperator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: RIVER POINT LANDING Date of Testing: U I-I�-13 <br /> Facility Address: 4950 BUCKLEY CLOVE WAY STOCKTON CA <br /> Facility Contact: ANDREW Phone: 209-951-414.4 <br /> Date Local Agency Was Notified of Testing:1-7-13 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO JEFF WONG <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 A Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo 0 David A.Winkler [K Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: M ICC Service Tech. SWRCB Tank Tester <br /> 3. SPILL BUCKET_TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/1120 Equipment Resolution: 1,116 <br /> Identify Spill Bucket(By Tank I DIESEL 2 87 3 -i <br /> Numher, Stored Product, etc.) <br /> 9 Direct Bury ®Direct Bury ❑ Direct Bury 0 Direct Bury <br /> Bucket Installation Type: El Contained in L1 Contained in <br /> ❑ Contained in Surnp []Contained in Sump Sum. Sum <br /> Bucket Diameter: 1 I I I <br /> Bucket Depth: 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 1000 1000 <br /> Initial Reading(Rj): 12 13 <br /> Test End Time(TF): 1100 1100 <br /> Final Reading(110: 12 13 <br /> Test Duration(TF—Tj): I HOUR I HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: X 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 TES'T'ING <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:01-1543 <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 />