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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: QUICKI KLEEN CAR WASH I Date of Testing: 10/24/12 <br /> Facility Address: 707 YOSEMITE BLVD MANTECA, CA 953336 <br /> Facility Contact: FRANCINE Phone: <br /> Date Local Agency Was Notified of Testing:10/1/12 <br /> Name of Local Agency Inspector(ifpresent during testing): MUNI <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 /> Identify Spill Bucket(By Tank 1 87-1 2 87-2 3 4 DIESEL <br /> Number, Stared Product, etc. <br /> ❑Direct Bury ❑Direct BuryDirect Bury Direct Bury <br /> Bucket Installation Type: ®Contained in Sump ®Contained in Sump El Contained in Su Contained in <br /> Sump Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 16 17 15 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1118 1118 1150 <br /> Initial Reading(R,): 14 3/4 15 3/4 13 1/2 <br /> Test End Time(Tr): 1218 1218 1250 <br /> Final Reading(RF): 14 3/4 15 3/4 13 1/2 <br /> Test Duration(Tr—T,): HR HR HR HR <br /> Change in Reading(Rr-R,): 1 0 0 1 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test.Result: I ® Pass ❑ Fail ® Pass ❑Fail I ❑ Pass ❑ Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed 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: <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 />