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SWRCB,Januaiy 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: JSKS ARCO I Date of sja&17V L.D. <br /> Facility Address: 1100 S MAIN ST MANTECA CA <br /> Facility Contact: Jesse K Phone: APR 18 ZU11 <br /> Date Local Agency Was Notified of Testing:3-7-17 <br /> Name of Local Agency Inspector(if present during testing): AARON Ei\ivignNMENTAL HEALTH <br /> 2. TESTING CONTRACTOR INFORMATION DEEPARTMENT <br /> Company Name: AFFORDA TEST 4162 d 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 89 4 <br /> Number,Stored Product, etc. <br /> El Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑Direct Bury E]Direct Bury ®Contained in ❑Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 l 1 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1 1 1 <br /> Initial Reading(Ri): 13 13.50 13 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): 13 13.50 13 <br /> Test Duration(TF—TI): 1 HR IHR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 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 <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: Td- -i Date 3-28-17 <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 />