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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 RD AMPM Date of Testing; -8--2 1( <br /> Facility Address: 4855 S HWY 99 STOCKTON CA ` <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:2-8-16 JUN 06 2016 <br /> Name of Local Agency Inspector(f present during testing): STACY ,_,. .. <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: ❑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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 187 W 2 91 3 DSL 4 87E <br /> Number, Stored Product, etc. <br /> ❑ Lj <br /> Bucket Installation Type: Direct Bury ❑Direct Bury Direct Bury ❑Direct Bury <br /> ® ®Contained in Contained in Sump ® Contained in Sump ®Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 I 1 11 1 I <br /> Bucket Depth: 14 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 905 905 905 905 <br /> Initial Reading(Ri): 13 13 12.50 13 <br /> Test End Time(TF): 1005 1005 1005 1005 <br /> Final Reading(RF): 13 13 12.50 13 <br /> Test Duration(TF—Tt): IHR 1HR IHR IHR <br /> Change in Reading(RF-Rt): 1 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16 I/16 1/16 1/16 <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing and recommended ollow-up for ailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: �7 — Date 2-8-2016 <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 />