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SNi-RCB.Januan_ 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of'L`ST spill containment structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the facility ow=neri'operator for submittal to the local regulators•agent-,-. <br /> 1. FACILITY Ili IF01CMATION <br /> Facility Name: J AND L MARKET Date of Testing: 05-27-10 <br /> Facility Address: 8125 EL DORADO STOCKTON CA <br /> Facility Contact: ! Phone: <br /> Date Local Agency Was Notified of Testing:05-04 <br /> Name of Local Agency Inspector(►f present during testing): SA\'JOAQL IN CO. RAY VO--\ FLUE <br /> 2. TESTING CO' TR-kCTOR INFORNLkTIO\ <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 Fax:(_'OI)-44-0116 <br /> Technician Conducting Test: ElLyle D.Nimmo ❑ Zane A.Nimmo ElDavid A. Winkler ® Felix G.Ramirez <br /> S 5249115-UT 5263322-U'T 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTLNG LN- FORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑Other <br /> 'i Test Equipment Used: TAPE H2O Equipment Resolution: 1 16 <br /> i <br /> Identify Spill Bucket(B'r Tank �' 1 87 2 91 3 DIE 4 <br /> \'umber. Stored Product, etc.) <br /> ® Direct Bury ®Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ` �11 ❑ Contained in Sump ❑ Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> I Bucket Depth: 14 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 900 i <br /> Initial Reading(Rj): 13 12 13 <br /> Test End Time(TF): 1000 1000 1000 ' <br /> Final Reading(RF): 13 12 13 <br /> Test Duration(TF-Tj): 1 HOUR I HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or j <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments- (include information on repairs made prior to testing, and n•econtntended follotic-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: <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 />