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R E C E VV <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form AUG 2 3 2018 <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 subm1"Y3P&QW ffiVXtoragency. <br /> 1. FACILITY INFORMATION HEALTH DEPARTS ENT <br /> Facility Name: PERSHING BEACON I Date of Testing: 01-31-18 <br /> Facility Address: 4445 NORTH PERSHING 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(if present during testing): SAN JNOAQUIN CO. ELIANNA FLORIDO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ®Ed Sterns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 814188-UT 8211269-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: TAPE/H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 87 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: I I 11 I I <br /> Bucket Depth: 15 15 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 900 900 900 <br /> Initial Reading(Rj): 14 14 14 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading`RF): 14 14 14 <br /> Test Duration(TF—Ti): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® 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 /> 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: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 />