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Spill Bucket Testing Report Form <br /> JUN 17 ATxcB,January 2006 <br /> ^^.f 'i <br /> This form is intended for use by contractors performing annual testing of UST spill containmenC� trugtu` fhe 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: J & L MARKET I Date of"besting: 5/26/2016 <br /> Facility Address: 8125 S. ELDORADO ST. FRENCH CAMP, CA 95231 <br /> Facility Contact: EUGENIA Phone: <br /> Date Local Agency Was Notified of Testing:4/26/16 <br /> Name of Local Agency Inspector(if present during testing): STACY <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: 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 Buy ❑ Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> El Contained in Sump E]Contained in Sump Sump Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 13 3/4 13 1/4 13 7/8 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 0925 0925 0925 <br /> Initial Reading(Ri): 12 1/8 12 - 12 7/8 <br /> Test End Time(TF): 1025 1025 1025 <br /> Final Reading(RF): 12 1/8 12 - 12 7/8 <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 ❑ Pass ❑ Dail I ® Pass ❑ Fail ® Pass ❑ 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 A 4EEP Date:5-26-16 <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 />