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r s <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: JAMAR SVC IDate of Testin : 05-01-17 <br /> Facility Address: 4075 EAST AMIN STREET STOCKTON CALIFORNIA <br /> Facility Contact: JASON Phone: 209462 8 ---- <br /> Date Local Agency Was Notified of Testing:04-19-17 <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO VIKI MAY 3 0 2017 <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMENTAL HEALTH <br /> Company Name: AFFORDA TEST 4162 nl Street Galt,CA 95632 (209)744-011UFRAPGT�lWTT116 <br /> Technician Conducting Test: ❑Ed Steams ❑ Zane A.Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br /> 89184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® [CC 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 tinE] <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury ❑ Direct Buect Bury <br /> Bucket Installation Type: ❑Containedntained in❑ Contained in Sump ❑Contained in SumpSum <br /> Bucket Diameter: 11 I I <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 910 910 <br /> Initial Reading(Rj): 13 12 <br /> Test End Time(TF): 1010 1010 <br /> Final Reading(RF): 13 12 <br /> Test Duration(TF—Tt): 1 HOUR I HOUR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 0 0 0 0 <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail ❑ Pass <br /> ❑Fail.. El Pass El Fail <br /> Comments—(include information on repairs made prior m 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 /> 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 />