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AEGF.iVEL., <br />SWRCB January 2006 <br />Spill Bucket Testing Report Form APR 0 2015 <br />This form is intendedfor use by contractors performing annual testing of UST spill containment structuFe'si'.,eomple" <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the /oca �-egtrlatory� <br />1. FACILITY INFORMATION <br />Facility Name: WATERLOO SHELL Date of Testing: 4/2/2015 <br />Facility Address: 4315 E. WATERLOO RD STOCKTON, CA 95205 <br />Facility Contact: RUPI Phone: <br />Date Local Agency Was Notified of Testing :2/24/2015 <br />Name of Local Agency Inspector (if presem (luring testing): AR1S <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2°d 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 (liv Tank <br />,'Number, Stored Product, etc.) <br />1 87 <br />2 <br />3 91 <br />4 <br />Bucket Installation Type: <br />F-1 Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />El Contained in Sump <br />Direct Bury <br />® Contained in <br />Sump <br />❑Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />19 <br />20 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1113 <br />1113 <br />Initial Reading (Rt): <br />15 1/8 <br />14 1/2 <br />Test End Time (TF): <br />1213 <br />1213 <br />Final Reading (RF): <br />15 1/8 <br />14 1/2 <br />Test Duration (TF - Tt): <br />HR <br />HR <br />Change in Reading (RF -R,): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ 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' - Date: -4-2-15 <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 />