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• W V �`ED <br /> r <br /> Spill Bucket Testing Report Form <br /> MAY 19 stW,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment s{'u cq ��d�m and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator fokdkF� dl Pr'la7'ory agency. <br /> nmpAmTtA _ T <br /> 1. FACILITY INFORMATION <br /> Facility Name: MANTECA LIQUOR FOOD Date of Testing: 4-24-17 <br /> Facility Address: 890 N MAIN ST MANTECA CA 95336 <br /> Facility Contact: JEET Phone: <br /> Date Local Agency Was Notified of Testing:3-29-17 <br /> Name of Local Agency Inspector(ifpresent during testing): AARON <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: ❑Ed Steams ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 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 DSL 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> El Contained in El Contained in <br /> ❑Contained in Sump El Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 12.50 12.50 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 930 930 930 <br /> Initial Reading(Ri): 12.50 12.50 13 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 12.50 12.50 13 <br /> Test Duration(TF—Tt): IIIR IHR 1HR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> ,_ ltkesult. ® Pass ❑Fail ® Pass. ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-up forfailed tests) <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 /> 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 />