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0 9 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: 2-8--2016 <br /> HV <br /> VY Address: 4855 S HY 99 STOCKTON CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:2-8-16 <br /> 11 <br /> Name of Local Agency Inspector(ifpresent 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: h2O and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87W 2 91 3 DSL 4 87E <br /> Number, Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury <br /> Direct <br /> Type: ❑ CDirectontained <br /> Bury ❑ Bury Su Contained n Su Contained in <br /> Bucket Installation T <br /> � ®Contained in Sump ®Contained in Sump 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: 905 <br /> I Test Start Time(TI): 905 905 905 <br /> Initial Reading(Ri): <br /> 13 13 12.50 13 <br /> Test End Time(TF): 1005 1005 1005 1005 <br /> Final Reading(RF): <br /> 13 13 12.50 13 <br /> Test Duration(TF—Ti): IHR <br /> IHR 0 1HR <br /> Change in Reading(RF-Rt): 0 <br /> 0 . 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: ; <br /> Comments— (include information on repairs made prior to testing, and recommendedfollow-u for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in thia report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ` 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 />