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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This farm is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SJ RTD I Date of Testing: 05-15-13 <br /> Facility Address: 1535 E LINDSAY ST STOCKTON CA 95205 <br /> Facility Contact: DOUG Phone: 209-467-6671 <br /> Date Local Agency Was Notified of Testing:04-16-13 <br /> Name of Local Agency Inspector(f present daring testing): SAN JOAQUIN CO.JEFF WONG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler N Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: M ICC Service Tech. M SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 DIESEL 1 2 DIESEL 2 3 DIESEL3 4 DIESEL 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: M Contained in N Contained in <br /> M Contained in Sump M Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 900 900 900 900 <br /> Initial Reading(R,): 12 12 12 12 <br /> Test End Time(Tr): 1000 1000 1000 1000 <br /> Final Reading(RP): 12 12 12 12 <br /> Test Duration(TF—T,): - 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R): 0 1 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> IlTest Result: N Pass ❑Fail I N Pass ❑ Fail 1 M Pass ❑ Fail I N Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-up forfailed tests) <br /> OPW BUCKETS <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:05-I5-13 <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 />