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• •R ry C E I1�2ZanuDa 2006 <br /> Spill Bucket Testing Report Form 016 <br /> SEP 2 9 2 <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 re lot cy. <br /> 1.FACILITY INFORMATION ENVIRONM... . �La� <br /> Facility Name: MY MINI MART Date of Tes "WWI 016 <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(ifpresent during testing): ARIS C. <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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. ®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 /> ._ -.-_. .- _ <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 <br /> tlumber, Stored Product, etc. <br /> Bucket Installation Type: ®Direct Bury ❑ Direct Bury <br /> ®Direct Bury ❑Direct Bury <br /> YP El Contained in Sum E]Contained in El Contained in <br /> Sump El in Sump Sump Sum <br /> Bucket Diameter: I I I 1 <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(111): 13 13 <br /> Test End Time(TF): 1345 1345 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—Ti): HR HR <br /> Change in Reading(RF-R[): 0 0 <br /> Pass/FaiI Threshold or <br /> Criteria: - -- -- <br /> Test Result: Z Pass ❑ Fail ❑ Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing and recommended ollow-up forfailed 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 />