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• • 'IEUEIVED <br />Spill Bucket Testing Report Form FP" I ,Cmoary 2006 <br />A',, <br />This form is intended for use by contractors performing annual testing of UST spill containment strue'( lied <br />printouts from tests (ifapplicable), should be provided to the facility owner/operator for submittal to the56caTi$ff <br />p§AhTy. <br />1. FACILITY INFORMATION <br />Facility Name: ERNIE GENERAL STORE Date of Testing: 01-29-16 <br />Facility Address: 4407 WATERLOO RD STOCKTON CA <br />Facility Contact: ERNIE Phone: 931-2850 <br />Date Local Agency Was Notified of Testing :1-13-16 <br />Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO <br />IT <br />11VtV <br />Company Name: AFFORDA TEST 4162 n1 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': E ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE/H20 <br />Equipment Resolution: 1/16 <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DIESEL <br />Bucket Installation Type: <br />yP <br />® Direct Bury <br />Sump <br />El Contained in Sum <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />F1 Contained in <br />Sump <br />L] Direct Bury <br />ElContained in <br />Sum <br />Bucket Diameter: <br />I I <br />1 I <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (T,): <br />935 <br />935 <br />935 <br />Initial Reading (R,): <br />12 <br />12 <br />12 <br />Test End Time (TF): <br />1035 <br />1035 <br />1035 <br />Final Reading (RF): <br />12 <br />12 <br />12 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - R,): <br />0 <br />0 1 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail I <br />E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended ollow-up orfailed 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:01-29-16 <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 />