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is�'��� <br /> Spill Bucket Testing Report Form JUN January 2006 <br /> f f Y performing g fspillrr r'tt -P f <br /> Thisform is intended or use b contractorsannual testis o UST containment structure. n1 pa?m leted orm and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: TRACY 76 1 Date of Testing: 5-3-2016 <br /> Facility Address: 2420 W GRANT LINE RD TRACY CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4-12-16 <br /> Name of Local Agency Inspector(ifpresent during testing): V ICKY SJV <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"'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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number,Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in El Contained in <br /> El Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 i l <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying -- -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 930 930 930 <br /> Initial Reading(Ri): 14 14 14 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 14 14 14 <br /> Test Duration(TF—Ti): 1 HR l HR IHR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16 I/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 /> OPW FLAPPERS <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 kith legal requirements. <br /> Technician's Signature: Vlz�—j Date 5-3-2016 <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 />