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" • • JUIO*�7January2006 <br /> Spill Bucket Testing Report Form ~*w1bl_ <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures:Tie 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 I Date of Testing: 05-23-16 <br /> Facility Address: 4075 EAST AMIN STREET STOCKTON CALIFORNIA <br /> Facility Contact: JASON Phone: 209-4624685 <br /> Date Local Agency Was Notified of Testing:04-26-16 <br /> Name of Local Agency Inspector('(present during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler E Felix G.Ramirez <br /> 5249115-UT 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 /> El®Direct Bury ®Direct Bury oma Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1200 1200 <br /> Initial Reading(Rt): 13 12 <br /> Test End Time(TF): 1300 1300 <br /> Final Reading(RF): 13 12 <br /> Test Duration(TF—Tt): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rt): 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Resalt: ® Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑Fail El Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUKCETS <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: 5-23-16 <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 />