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RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form 2016 <br /> This farm is intended for use by contractors performing annual testing of UST spill containment structgokpjlJ��t�l(fOrpm�and <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operator for submittal tA �'� '(^AIAI`aR'-1 ,�'7tEj�YglvJGe I Y• <br /> 1.FACILITY INFORMATION <br /> Facility Name: QUICK KLEEN Date of Testing: 10-21-15 <br /> Facility Address: 707 E YOSEMITE AVE MANTECA CA <br /> Facility Contact: Phone: 209-814-3726 <br /> Date Local Agency Was Notified of Testing:9-24-15 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <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 ❑ David A.Winkler N 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 87 3 91 4 <br /> Number, Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury El Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> N Contained in Sump N Contained in SN Contained in ❑Contained in <br /> ump SUMP Sum <br /> Bucket Diameter: I I l I l l <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 1300 1300 1300 <br /> Initial Reading(R,): 13 13 13 <br /> Test End Time(TF): 1400 1400 1400 <br /> Final Reading(RF): 13 13 13 <br /> Test Duration(TF—Ti): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑Fail N Pass ❑Fail N Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> QPW BUCKETS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the <br /> information <br /> contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: U ' Date:10-21-15 <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 />