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• SWRCB,January 2006 <br /> Spill Bucket Testing 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SAVE ON GAS I Date of Testing: 04-29-14 <br /> Facility Address: 420 WEST YOSEMITE MANTECA CALIFORNIA 95336 <br /> Facility Contact: SAM Phone: 209-267-44 RIVE <br /> Date Local Agency Was Notified of Testing:04-08-14 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO. Mtn, 3 U 2014 <br /> 2.TESTING CONTRACTOR INFORMATIONp� TT <br /> Company Name: AFFORDA TEST 416 2""Street Galt,CA 95632 (209)744-0 rcvyJ� �O�T6 <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: ®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: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury ❑ Direct Bury E]Direct Bury <br /> Bucket Installation Type: E] Contained in E:1 Contained in <br /> ElContained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: I I 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 900 900 <br /> Initial Reading(111): 121/2 123/4 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 12 1/2 123/4 <br /> Test Duration(TF—Tj): I HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑Fair <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:04-29-14 <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 />