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MEMO <br /> Spill Bucket Testing Report Form <br /> SEP 1 9 2017RCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containmeMPA$WWkL7h@ dbhtpleted form and <br /> Printou[s om tests(tfaPltcable). should be provided to thefacility owner/o era[orfar submittahfiocareSulatorY agency <br /> 1.FACILITY INFORMATION <br /> Facility Name: ARCH AP PM I Date of Testing: 02-14-17 <br /> Facility Address: 4855 S HWY 99 STOCKTON CA 95205 <br /> Facility Contact: Gil or Nima Phone: 209-688-7036 <br /> Date Local Agency Was Notified of Testing:01-24-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO VIKI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"a 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 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/H20 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 489 <br /> Number,Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury <br /> El Direct Bury E]Direct Bury <br /> Bucket Installation Type: Su Contained in Su Contained in <br /> ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 I1 <br /> Bucket Depth: 14 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 930 930 930 930 <br /> Initial Reading(Rj): 13 13 13 13 <br /> Test End Time(TF): 1030 1030 930 930 <br /> Final Reading(RF): 13 13 12 12 <br /> Test Duration(TF—T[): 1 HOUR 1 HOUR - - <br /> Change in Reading(RF-Rj): 1 0 1 0 1 1 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ®Fail ❑ Pass ® Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> WAS ABLE TO SEE BUCKET LEAKING INTO SUMP <br /> REPAIRS TO BE DONE BY ELITE IV <br /> ALL BUCKETS MEASURED MORE THEN 5 GALLONS <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:02-14-17 <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 />