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01 <br /> APR 11 2MCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill contain�eht stl "oc127 form and <br /> printoutsfrom tests(ifapplicable), should be provided to thefacility owner/operatorfor submittal to egulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: WATERLOO SHELL Date of Testing: 4-6-2016 <br /> Facility Address: 4315 E WATERLOO RD STOCKTON CA <br /> Facility Contact: RUPI Phone: <br /> Date Local Agency Was Notified of Testing:2-24-16 <br /> Name of Local Agency Inspector(f present during testing): FATINA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211 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 /> West 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 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sump 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(Tj): 930 930 <br /> Initial Reading(Rj): 18 18 <br /> Test End Time(TF): 1030 1030 <br /> Final Reading(RF): 18 18 <br /> Test Duration(TF—TI): 1 HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail I ❑ 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 w flappers <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: r1 �`—' Date 4-6-2016 <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 />