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• <br /> +yy r � Zol�WRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spil inment structures: The complf+d form and <br /> printouts from tests(if applicable), should be provided to the facility owner/opera ma a'ubmitta/to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: JAMAR SVC Date of Testing: 05-01-17 <br /> Facility Address: 4075 EAST AMIN STREET STOCKTON CALIFORNIA <br /> Facility Contact: JASON Phone: 209-462-4685 <br /> Date Local Agency Was Notified of Testing:04-19-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO VIKI <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 Stearns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 89184188 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 91 3 4 <br /> Number,Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury <br /> ® Direct Bury ®Direct Bury E]Contained in EI in <br /> El Contained in Sump E]Contained in Sump <br /> Bucket Installation Type: <br /> Sump Sum <br /> Bucket Diameter: 1 I 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 910 910 <br /> Initial Reading(R): 13 12 <br /> Test End Time(Tr): 1010 1010 <br /> Final Reading(RF): 13 12 <br /> Test Duration(TF—Tj): IHOUR IHOUR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: 11 E Pass ❑ Fail ® Pass ❑Fail I ❑ Pass ❑ Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> OPW BUKCETS <br /> ALL BUCKETS HOLD 5 GALLON CAPACITY <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 /> l� <br /> Technician's Signature:_ _ Date 5-1-17 <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 />