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SWRCB, January 2006 <br />Spill Bucket Testing Deport 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 ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: PERSHING GAS I Date of Testing: 1-30-17 <br />Facility Address: 4445 N PERSHING STOCKTON CA 95207 <br />Facility Contact: Daljit Singh Phone: 477-8004 <br />Date Local Agency Was Notified of Testing :1124117 <br />Name of Local Agency Inspector (tf present during testing): VICKI <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2id Street Galt, CA 95632 (209) 7 4,-0112 Foix: (209) 744-01 '16 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo Z David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ® ICC Service Tech. ❑ SWRCB Tank Tester V <br />3_ CPTIJ. RlrTf KFT TIFCTTNI'_ 1NFn12MAT1nN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure <br />I Equipment Resolution: 1/16 <br />Identify Spill Bucket (BY lank <br />Xumber, Slored Product. etc.) <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />® Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />I 1 <br />11 <br />11 <br />Bucket Depth: <br />1 14.25 <br />13.75 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />Test Start Time (Ti): <br />1 <br />1 <br />1 <br />Initial Reading (Rt): <br />13 <br />13 <br />13 <br />Test End Time (TF): <br />2 <br />2 <br />2 <br />Final Reading (RF): <br />13 <br />13 <br />13 <br />Test Duration (TF — Tj): <br />1 HR <br />1 HR <br />IHR <br />Change in Reading (RF- Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1116 <br />1/16 <br />Test Result; <br />® Pass ❑ Fail <br />Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include in or•mation on repairs made prior to testin,and recommended allow -u or ailed tests) <br />OP'W ALL PASSED <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: <br />I1IIm''- SLOB&A <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 />