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0 & 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 (ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Quick&Easy Food Mart I Date of Testing: 06-25-15 <br /> Facility Address: 824 EAST YOSEMITE AVE MANTECA CALIFORNIAL, <br /> Facility Contact: I Phone: 209-239-17 2 <br /> Date Local Agency Was Notified of Testing:06-22-15 <br /> Name of Local Agency Inspector(tfpresent during testing): SAN JOAQUIN CO SEP 02 2 <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMENTAL. <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 E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 89 4 <br /> Number, Stored Product, etc. <br /> E Direct Bury E Direct Bury E Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑ Contained in El Contained in <br /> ElContained in Sump ElContained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I 1 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1300 1300 1300 <br /> Initial Reading(RO: 13 13 13 <br /> Test End Time(TF): 1400 1400 1400 <br /> Final Reading(RF): 13 13 13 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail ❑ Pass ❑ Fail <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: �f� Date:06-25-15 <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 />