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• 4hEDEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUL,1128% <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The comp nd <br /> printouts from tests(if applicable), should be provided to the facility owner/operatorfor s&CWR0 ME4ThL <br /> 1.FACILITY INFORMATION DEPARTMENT <br /> Facility Name: MY MINI MART Date of Testing: 6-23-2014 <br /> Facility Address: <br /> Facility Contact: LAL Phone: <br /> Date Local Agency Was Notified of Testing:6-2-14 <br /> Name of Local Agency Inspector(ifpresent during testing): JEFF <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> El Lyle D.Nimmo El Zane A.Nimmo ® David A.Winkler El Felix G.Ramirez <br /> Technician Conducting Test: 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 I/l6 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number,Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury El Contained in El Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: I1 I 1 <br /> Bucket Depth: 13.50 13.50 <br /> Wait time between applying -- <br /> vacuum/water and start of test: <br /> Test Start Time(Tl): 9 9 <br /> Initial Reading(R,): 13 13 <br /> Test End Time(TF): 10 10 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—T,): IHR IHR IHR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail ' ❑ 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: TC*)--j Date 6-23-2014 <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 />