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Spill Bucket Testing Report Form SWRCB,January 2006 <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: 4-17-15 <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 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO. -ELENA MAY -2 9 2015 <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMENTAL <br /> T AIT <br /> Company Name: AFFORDA TEST 416 2nd 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: ®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 /> Bucket Installation Type: ®Direct Bury ® Direct Bury ❑ Direct Bury ❑Dvect Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in ❑ Contained in <br /> Bucket Diameter. 11 11 Sum Sum <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj: 900 900 <br /> Initial Reading(Ri): M1313 <br /> Test End Time(TF): <br /> Final Reading(RF):Test Duration(TF—Tj):Change in Reading(RF-Rj):Pass/Fail Thresholdor <br /> riteria:Test Result: LEIPass il ❑ 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 /> 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 />