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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UoST spill <br /> containment <br /> structures.the local r guThe comlatorypletedfage orm and <br /> printouts from tests (if applicable), should be provided to the facility o p fubmittal <br /> Ni AU H Ui Nei <br /> 1.FACILITY INFORMATION <br /> Facility Name: WATERLOO SHELL <br /> Date of Testing: 10-2-2013 <br /> Facility Address: 4315 E WATERLOO RD STOCKTON CA <br /> Facility Contact: RUPI <br /> Phone: <br /> Date Local Agency Was Notified of Testing:9-11-13 GARRET <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> 209 744-011TFax: 09)744-0116Company Name: AFFORDA TEST 416 2°d Street Galt,CA 95632 ( )Lyle D.Nimmo ❑ Zane A.Nimmo ® David A.Winkler ❑ FamirezTechnician Conducting Test: 5249115-UT 5263322-UT 5263373-UT -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 <br /> Equipment Resolution: 1/16 <br /> 3 4 <br /> Identify Spill Bucket(By Tank 1 87 <br /> Number, Stored Product, etc.) <br /> Direct Bury ❑ Direct Bury <br /> C Direct Bury ❑ Direct Bury ❑Contained in ❑ Contained in <br /> Bucket Installation Type: ® Contained in Sump ® Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 19 19 <br /> Wait time between applying - -- <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1145 1145 <br /> Initial Reading(Rj): 18 18 <br /> Test End Time(TF): 1245 1245 <br /> Final Reading(RF): 18 18 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> Criteria: 1i <br /> PASS ❑ /r uP . n. <br /> Test Result: ® Pass ❑Fail � ,.,.. N ...... , , <br /> Comments— (include information on re airs made prior to testing, and recommended follow-up for failed tests) <br /> o W W fla ers <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONI)tiCTING 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: T�3—) <br /> Date 10-2-13 <br /> 1 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 />