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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: ARCH ROAD AMPM I Date of Testing: 2-13-18 <br /> Facility Address: 4855 S HWY 99 STOCKTON CA 95205 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): ELIANA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns ❑ Zane A.Nimmo M David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials': M ICC Service Tech. M SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: M Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure I Equipment Resolution: I/I6 <br /> Identify Spill Bucket (By Tank 1 87W 2 91 3 DSL 4 87E <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ElDirect Bury M Contained in Sump M Contained in Sump M Contained in M Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 11 <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(111): 13 13 13 13 <br /> Test End Time(TF): 1030 1030 1030 1030 <br /> Final Reading(RF): 13 13 13 13 <br /> Test Duration(TF—Tj): IHR IHR IHR IHR <br /> Change in Reading(RF-RI): 0 0 1 0 1 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: M Pass '_E Fail M Pass ❑ Fail M Pass ❑Fail I M 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: xl "�— JDate 2-13-18 <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 />