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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form MAY 14 2015 <br /> This form is intended for use by contractors performing annual testing of(IST spall containment structures. The completed form and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the tocol regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: ALPHA FAST GAS Date of Testing: 4-23-2015 <br /> Facility Address: 2358 WATERLOO RD <br /> Facility Contact: .TIMMY Phone: <br /> Date Local Agency Was Notified of Testing:3-27-15 <br /> Name of Local Agency Inspector(f present during testing): STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Al{FORDA TEST 416 2'6 Street Galt,CA 95632 (209)744-011.2 Fax: (209)744-0116 <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 /> Credentials': ® ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1116 <br /> Identify Spill Bucket (Biy Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) —— :]l— <br /> ® Direct Bury Direct Bury [K Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ElContained in ❑Contained in <br /> F1Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 1 I I 1 <br /> Bucket Depth: 12 12 15.50 <br /> Wait time between applying -_ -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1 1 T <br /> Initial Reading(R,): 11 11 14.50 <br /> Test End Time(TF): <br /> 2 2 2 <br /> Final Reading(RF): <br /> 11 11 14.50 <br /> Test Duration(Tr—Tj): 1 HR IHR I HR <br /> Change in Reading(RF-R[): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1116 1116 <br /> Criteria: <br /> Test Result: I ® Pass ❑Fail ® Pass ❑ Fail I ® Pass [] Fail ❑ Pass [:] 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: Date 4-23-2015 <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 />