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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: SJRTD I Date of Testing: 6-22-2012 <br /> Facility Address: 1533 E LINDSAY RD STOCKTON CA <br /> Facility Contact: DOUG Phone: <br /> Date Local Agency Was Notified of Testing:5-8-12 <br /> Name of Local Agency Inspector(ifpresent during testing): JEFF <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 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: H2O &TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank BLD I BLD 2 BLD 3 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury ® Direct Bury ®Direct Bury <br /> Bucket Installation Type: ElContained in Sump E] Contained in Sump ❑ Contained in ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 11 11 11 <br /> Initial Reading(RI): 13 12 12 <br /> Test End Time(TF): 12 12 12 <br /> Final Reading(RF): 13 12 12 <br /> Test Duration(TF—TI): 1 HR I HR I HR <br /> Change in Reading(RF-Ri): 0 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ®, Pass ❑ Fail Z Pass '❑ Fail ass ❑ 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: T&--j Date 6-22-12 <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 />