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• • 0 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. FACTI,TTV TNFORMATION <br />Facility Name: THORNTON 76 _ Date of Testing: 5/3/10 _ <br />Facility Address: 8606 THORNTON RD. STOCKTON, CA 95209 <br />Facility Contact: AMBA Phone: 209-478-8959 _ <br />Date Local Agency Was Notified of Testing :3/2/10 <br />Name of Local Agency Inspector (lfpresent during testing): GARRETT BACKUS <br />2. TESTING C0N'1'RAU'I'UR 1NN'0RMA'1'1U1N <br />Company Name: AFFORDA TEST 4162 nd 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 />11 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPTT.L RACKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 !37 <br />C <br />2 91 <br />3 89 <br />4 <br />_ <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <br />I 1 <br />11 <br />_ <br />Bucket Depth: <br />I 1 <br />10 1/2 <br />12 1/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />-- <br />_ <br />Test Start Time (Ti): <br />0900 <br />0900 <br />0900 <br />Initial Reading (111): <br />10 <br />9 1/2 <br />11 1/4 <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (RF): <br />10 <br />9 1/2 <br />11 1/4 <br />Test Duration (TF — Tj): <br />HR <br />HR <br />HR <br />Change in Reading (RF- Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow -zip for,/ailed 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:—� Date:5-3-10 <br />State laws and regulations do not currently require testing to be perfotmed by a qualified contractor. However, local requirements <br />may be more stringent. <br />