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op . • • 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: ORLANDOS MARKET Date of LeMiF ` 7-11-2017 <br />Facility Address: 18754 E HWY 26 LINDEN CA 95236 rj ! <br />Facility Contact: BRANDON Phone: 209-887-1100 <br />Date Local Agency Was Notified of Testing :6-26-17 AUh 1 <br />Name of Local Agency Inspector (ifpresent during testing): STACY SIC <br />FN\/IRnFF,11!--NTA HF, -!T -i <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 />8184188 5263322 -UT 5263373 -UT 5273934 -UT <br />u Credentials': M ICC Service Tech. M SWRCB Tank Tester II <br />3- SPTI.I. RITCKF.T TFCTYN(_ INFORMATION <br />Test Method Used: M Hydrostatic ❑ Vacuum [-I Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />2 91 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />3 DIESEL <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />M Contained in Sump <br />E]Direct Bury <br />M Contained in Sump <br />M Direct Bury <br />❑ Contained in <br />Sum <br />ElDirect Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />12 <br />12 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />900 <br />900 <br />900 <br />Initial Reading (Ri): <br />11 <br />12 <br />14 <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (RF): <br />11 <br />12 <br />14 <br />Test Duration (TF — Tj): <br />1 HOUR <br />I HOUR <br />1 HOUR <br />Change in Reading (RF -Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />M Pass ❑ Fail <br />M Pass ❑ Fail <br />M Pass ❑ Fail <br />❑ 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:. W 7-11-17 <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 />