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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form \io\i p 2 2011 <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 ownerloperator f tt flftrMlqaAEM ncy <br /> 1. FACILITY INFORMATION s 117 T <br /> Facility Name: SUPER STORES INDUSTRIES Date of Testing: 10/6.2017 <br /> Facility Address: 16888 McKINLEY AVE. LATHROP,CA 95330 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:CESAR <br /> Name of Local Agency Inspector(if present during testing): 9/27/2017 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°8 Street Galt,CA 95632 (209)744-0112 Fax: (209) 744-01 16 <br /> Technician Conducting Test: ❑Ed Stearns Z Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 8211269 5263373-UT 5273934-UT <br /> Credentials': Z ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment C,sed: TAPE MEASURE, 1120 Cquipmertt Resolution: 1116" <br /> Identify Spill Bucket (By Tank 1 WEST DIESEL 2 NENN OIL 3 WASTE OIL 4 EAST DIESEL <br /> ,\urn6cr, Stored Product, etc.) <br /> Bucket Installation Type: ®Direct Bury ❑Direct Bury LlDirect Bury N Direct Bury <br /> L]Contained in Sump ®Contained in Sump ® Contained in Ll Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 12 12 11 <br /> Bucket Depth: 13 1/2 13 13 12 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -" <br /> Test Start Time(Ti): 1309 1309 1309 1309 <br /> Initial Reading(Ri): 12 112 11 314 12 11 112 <br /> Test End Time(TF): 1409 1409 1409 1409 <br /> Final Reading(RF): 12 1/2 11 314 12 11 1/2 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- <br /> Test Result: ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Pass F1 Fail <br /> Comments— (include in ormation on repairs made rior to testing, and recommended ollow-u or ailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDI`{'TING THIS FF:STING <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: 10-6-17 <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 />