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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(if 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 Date of Testing: <br /> Facility Address: 420 WEST YOSEMITE MANTECA CALIFORNIA <br /> Facility Contact: Paul Singh Phone: 267-4400 <br /> Date Local Agency Was Notified of Testing:3-26-15 MAY 2015 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO.-ELENA ENVIRONMEN <br /> AL <br /> 2.TESTING CONTRACTOR INFORMATION HEA!TunFoaoTA FhI <br /> Company Name: AFFORDA TEST 416 2"Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo N David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N 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 /> N Direct Bury N Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 900 900 <br /> Initial Reading(R,): 13 13 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑ Fail N Pass ❑ Fail ❑ 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Te hnician's Signature: . Date 4-17-15 <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 />