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SWRCB, January 2006 <br />Spill Bucket Toting 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: PERSHING BEACON Date of Testing: 01-3l-18 <br />Facility Address: 4445 NORTH PERSFUNG STOCKTON CA 95207 <br />Facility Contact: DALJIT Phone: 209-477-8004 <br />Date Local Agency Was Notified of Testing :01-24-18 <br />Name of Local Agency Inspector (f present during testing): SAN JNOAQUIN CO. ELIANNA FLORIDO <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: MEd Sterns ❑ Zane A. Nimmo ❑ David A. Winkler N Felix G. Ramirez <br />814188 -UT 8211269 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ❑ ICC Service Tech. ❑ SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />Identify Spill Bucket ()3y lank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 87 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ in Sump <br />® Direct Bury <br />❑Contained in Sump <br />E Direct Bury <br />E] Contained inContained <br />Sump <br />F]Direct Bury <br />Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />15 <br />15 <br />15 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Ti): <br />900 _ <br />900 <br />900 <br />Initial Reading (Ri): <br />14 <br />14 <br />14 <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (Rp): <br />14 <br />14 <br />14 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />- <br />- <br />Test Result: <br />Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up far failed tests) <br />()PW 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 -.01-31-18 <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 />