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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts om tests(f applicable), should be provided to the facility owner/o erator or submittal to the local regulatory en <br /> P .r a agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SYSTEM TRANSPORT <br /> Facility Address: 707 EAST ROTH FRENCH CAWCALIFORNIA Date of Testing: <br /> 05-23-13 <br /> Facility Co.,,_,,. SAM <br /> Date Local Agency Was Notified of Testing:04-10-13 Phone: 209-983-8654 <br /> Name of Local Agency Inspector(tfpresent during testing): SAN JOAQUIN CO. Thuy <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"Street Galt, CA 95632 <br /> (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo <br /> 5249115-UT ❑ David A. Winkler ® Felix G. Ramirez <br /> 5263322-UT 5263373-UT 5273934-UT <br /> Credentials':i ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used ®Hydrostatic <br /> Test Equipment Used: TAPE/H2O ❑Vacuum Other <br /> Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank I DIESEL <br /> Number, Stored Product, etc. 2 3 4 <br /> Bucket Installation Type: ®Direct Bury ❑ Direct Bury ❑Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in ❑ Contained in <br /> Bucket Diam er. 11 Sum Sum <br /> Bucket Depth 13 <br /> Wait time be een applying <br /> vacuum/water and start of test: <br /> Test Start Ti (Tt): 1200 <br /> Initial Readin (Ri): 12 <br /> Test End Tim (TF): 1300 <br /> Final Reading RF): 12 <br /> Test Duration i TF—Tj): 1 HOUR <br /> Change in Rea ling(RF-Rj): 0 <br /> Pass/Fail Thres old or <br /> Criteria: - <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑Fail <br /> ❑ Pass E] Fail El Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> EMCO B CKET <br /> CERTIFI ATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify hat all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Si nature: <br /> Date:05-23-13 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more s ingent. <br />