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R'CEIVED <br /> NOV 0 7 �JN CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill co (�?41 9kLcj"0"rm and <br /> printouts from tests(ifapplicable),should be provided to the facility owner/operator or su mitUUtb to Elatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: QUICKI KLEEN I Date of Testing: 10-11-16 <br /> Facility Address: 707 E YOSEMITE AVE MANTECA CA <br /> Facility Contact: FRANCENE Phone: 209-814-3726 <br /> Date Local Agency Was Notified of Testing:09-24-16 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <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 87 3 DIESEL 4 <br /> Number,Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ®Contained in E] Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 908 908 908 <br /> Initial Reading(Ri): 13 1/2 13 13 <br /> Test End Time(Tr): 1008 1008 1008 <br /> Final Reading(RF): 13 1/.2 13 13 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommendedfollow-upforfailed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS VERIFED TO HOLD AT LEAST 5 GALLON <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:ffoDate:10-11-16 <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 />