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S\\RCB,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(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 Date of Testing: 5/9/2017 <br /> Facility Address: 2420 W.GRANT LINE RD.RACY,CA 95376 ` y <br /> Facility Contact: Phone: 830-1139 P"" <br /> Date Local Agency Was Notified of Testing:4/20/2017 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION -- NMENTAL HEAL-1 <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112@06KK� 1716 <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 (4y Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ❑ Direct Bury <br /> ®Direct Bury ® Direct Bury <br /> Bucket Installation Type: ❑Contained in ElContained in <br /> ❑ Contained in Sump ElContained in Sump SumpSum <br /> Bucket Diameter: 11 I I 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(Rj): 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—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fa!Lj ® Pass ❑tail <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 />