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y Spill Bucket Testing Report Form SWRCB, January 2006 <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 FA rTT TTV TWUnDAa A'TT/11kT <br />Facility Name: WATERLOO SHELL Date of Testing: 1-5-10 <br />Facility Address: 4315 E WATERLOO RD STOCKTON CA <br />Facility Contact: RUPI Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): GARRET <br />2. TF.STTNC. C ONTR A (`T(lR 1NI4 t1D nn A 9rrnr`T <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744- <br />o' <br />44 - l 16 <br />Technician Conducting Test: El Lyle D. Nimmo El Zane A. Nimmo ®David A. Winkler El Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />C►•edentials': ®ICC Service Tech. ® SWRCB Tank Tester <br />CpTT T DTTt'TIL'T rrVQTTXTf_ YX y7 r, rirx A m__ <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />® <br />1 87 <br />2 91 <br />3 <br />4 <br />I <br />Bucket Installation Type: <br />®Direct Bur y <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury 1 <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <br />11 <br />Bucket Depth: <br />17 <br />19 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1200 <br />1200 <br />Initial Reading (Rj): <br />16 <br />17.50 <br />Test End Time (TF): <br />1300 <br />1300 <br />Final Reading (RF): <br />16 <br />17.50 <br />Test Duration (TF — Tj): <br />1 HR <br />I HR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑Pass ❑ Fail <br />—AXII„ IA11a — (inctuue injormaaon on repairs matte prior to testing and recommended ollow-up or 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: Tc_�_j <br />Date 1-5-10 <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 />