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w Y{�'tA) <br /> r � r <br /> SEP 5 N4RCB,January2006 <br /> Spill Bucket Testing Report Form <br /> - TH <br /> This form is intended for use by contractors performing annual testing of UST spill cE6inment structures. The completed form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the localregulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: TRACY 76 1 Date of Testing: 5/9/2017 <br /> Facility Address: 2420 W.GRANT LINE RD.RACY,CA 95376 <br /> Facility Contact: I Phone: 830-1139 <br /> Date Local Agency Was Notified of Testing:4/20/2017 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211 Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 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 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump ❑Contained in Sump ❑Contained in ❑Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 1/2 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0900 0900 0900 <br /> Initial Reading(RI): 13 1/2 13 1/8 13 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 13 1/2 13 1/8 13 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail E] Pass ElFail ® Pass ElFail ® Pass E]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 Date: 5-9-17 <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 />