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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: MANTECA LIQUOR&FOOD I Date of Testing: 4-16-18 <br /> Facility Address: 890 N MAIN ST. MANTECA,CA 95336 <br /> Facility Contact: JEET Phone: <br /> Date Local Agency Was Notified of Testing:3/20/18 <br /> Name of Local Agency Inspector(ifpresent during testing): JOHN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns ❑ Zane A.Nimmo N David A. Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-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: 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: N Direct Bury N Direct Bury N Direct Bury ❑Direct Bury <br /> yP ❑Contained in Sump El Contained in Sump ❑Contained in ElContained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 i 1 <br /> Bucket Depth: 12.50 12.50 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 930 930 930 <br /> Initial Reading(Rt): 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): IHR IHR 1HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <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 or failed 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 />