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LGEI V EI <br /> SEP 1 O;VvMB,January 2006 <br /> Spill Bucket Testing Report Forms A11/Ip��'nAR!;7gZaF111T;, <br /> Thisform is intended for use by contractors performing annual testing of UST spill contain�rle�yrkd�`�A� brmand <br /> printouts_from tests(fapplicable), should be provided to thefacility owner/operatorfor submit�al po 11'a'e locagency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: DELTA ARCO Date of Testing: 08-19-15 <br /> Facility Address: 440 WEST CHARTER WAY STOCKTON CA 95206 <br /> Facility Contact: MAJOR Phone: 209-465-=2487 <br /> Date Local Agency Was Notified of Testing:07-20-15 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank l 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 ElContained in <br /> ❑ Contained in Sump E]Contained in Sump SumpSum <br /> Bucket Diameter: 11 I 1 <br /> Bucket Depth: 13 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1000 1000 <br /> Initial Reading(Ri): 13 13 <br /> Test End Time(TF): 1100 1100 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—TI): I HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or <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 BUCKETS <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: t Date:08-19-15 <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 />