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RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUL 2 3 2014 <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 submEWFWMEWA"8AffH <br /> 1. FACILITY INFORMATION DEPARTMENT <br /> Facility Name: QUICK&EASY Date of Testing: 6-30-14 <br /> Facility Address: 824 YOSEMITE AVE MANTECA CA <br /> Facility Contact: Kahn Phone: <br /> Date Local Agency Was Notified of Testing:6-26-14 <br /> Name of Local Agency Inspector(ifpresent during testing): ELENA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 89 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> El Contained in El Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 15 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1215 1215 1215 <br /> Initial Reading(R,): 13 13.50 14 <br /> Test End Time(TF): 115 115 115 <br /> Final Reading(RF): 13 13.50 14 <br /> Test Duration(TF—T,): 1HR IHR IHR <br /> Change in Reading(RF-RI): 0 0 1 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑Fail ®. Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information,,,, <br /> rr-mattion contained in this report is true,accurate,and in full compliance with legal requirements. <br /> ������E.... <br /> Technician's Signature: Date 6-30-2014 <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 />