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, 1 <br /> 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: QUICKIKLEEN Date of Testing: 10-11-16 <br /> Facility Address: 707 E YOSEMITE AVE MANTECA CA <br /> Facility Contact: FRANCENE Phone: 209-81 3 <br /> Date Local Agency Was Notified of Testing:09-24-16 <br /> Name of Local Agency Inspector('(present during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION UUMNMENTAL HEALTH <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-0ffJP .gT1A T0116 <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: 11116 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® 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(Tt): 908 908 908 <br /> Initial Reading(Rt): 13 1/2 13 13 <br /> Test End Time(TF): 1008 1008 1008 <br /> Final Reading(RF): 13 1/.2 13 13 <br /> Test Duration(TF—Tt): ] 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 I E Pass ❑ Fail I ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include in/oomation on repairs made prior to testing, and recommendedfollow-up for failed 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: �r� Date: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 />