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ijEC ,•• IVEDRCB January 2006 <br /> Spill Bucket Testing Report Form AUG 0 5 2015 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The c 1 nd <br /> printouts from tests(f applicable), should be provided to the facility ownerlaperatorforsubewtR EpARTMEN SPI tttht gency. <br /> 1.FACILITY INFORMATION DEP <br /> Facility Name: MY MINI MART I Date of Testing: 6/28/2016 <br /> Facility Address: 1756 N. WILSON WAY STOCKTON, CA 95205 <br /> Facility Contact: Danny Phone: <br /> Date Local Agency Was Notified of Testing:6/7/2016 <br /> Name of Local Agency Inspector(fpresent during testing): ARIS C. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"a 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. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ❑ Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ElContained in ❑Contained in <br /> ❑ Contained in Sump E]Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1245 1245 <br /> Initial Reading(Ri): 13 13 <br /> Test End Time(TF): 1345 1345 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—T1): HR HR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 0 Pass ❑Fail ❑ Pass ❑Fail E Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for ailed tests) <br /> MEASURED 5 GALLONS <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: 6-28-16 <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 />