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• i <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: UNITED GAS Date of Testing: 6-27-13 <br /> Facility Address: 3440 E MAIN ST STOCKTON CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:5-15&6-3-13 <br /> Name of Local Agency Inspector(rfpresent during testing): Elena <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ® David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 527934-U7 <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: H2O&TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 89 4 <br /> Number,Stored Product, etc. <br /> ® Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 1 1 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 9 <br /> Initial Reading(RI): 12 12 12.14 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 12 12 12.14 <br /> Test Duration(TF—Tt): I HR 1 HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 1 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail I ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for 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: Date: 6-27-13 <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 />