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. • <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I.. 1 , i1.TL`An`%4 A Til1N <br />1. 1'HV1L11 a <br />Facility Name: JAMAR SERVICE VALERO Date of Testing: 5-15-2014 <br />Facility Address: 4075 E MAIN STREET STOCKTON CA <br />Facility Contact: JAY Phone: <br />Date Local Agency Was Notified of Testing :4-14-14 <br />Name of Local Agency Inspector (tfpresent during testing): JEFF WONG <br />2. <br />I WIN <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 II <br />n r .li,� TCCTIN/_ INT?nMVI A rlrnN <br />0. �....�ai.. �..�...� �.....�Y - <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />1 87 <br />2 91 <br />3 <br />4 <br />Number, Stored Product, etc.) <br />❑ Direct Bury <br />❑ Direct Bury <br />® Direct Bury <br />® Direct Bury <br />E] Contained in <br />❑ Contained in <br />Bucket Installation Type: <br />❑ Contained in Sump <br />❑ Contained in Sump <br />Sum <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />13 <br />Wait time between applying <br />-- <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1 <br />1 <br />Initial Reading (RI): <br />13 <br />12 <br />Test End Time (TF): <br />2 <br />2 <br />Final Reading (RF): <br />13 <br />12 <br />Test Duration (TF —Tj): <br />IHR <br />IHR <br />Change in Reading (RF-Ri): <br />0 <br />0 <br />Pass/Fail Threshold or <br />1/16 <br />1/16 <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />® Pass 01Fail <br />ElPass ElFail <br />E]Pass ElFail <br />Comments — (include information on repairs made prior to testing, and reeommenaeci ottow-up.lor,laaea aesle7 <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: <br />Date 5-15-2014 <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 />