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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 UST spill containment structures. The completed form and <br /> prinioutsfrom tests(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: DELTA ARCO Date of Testing: 08-29-I8 <br /> Facility Address: 440 W CHARTER WAY STOCKTON,CA 95206 <br /> Facility Contact: MAJOR Phone: 209-465-2487 <br /> Date Local Agency Was Notified of Testing:07-27-18 <br /> Name of Local Agency Inspector(iifpresent during testing): SAN JOAQUIN CO STACI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"^Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Steams ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials': ® ICC Service Tech. N 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 1 87 2 91 3 4 <br /> Number Stored Product etc. <br /> ®Direct Bury ® Direct Bury El Direct Bury El Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> El Contained in Sump ElContained in Sump Sump Sum <br /> Bucket Diameter: I 1 I I <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 906 906 <br /> Initial Reading(RI): 13 13 <br /> Test End Time(TF): 1006 1006 <br /> Final Reading(RF): 13 13 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rt): 1 0 1 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: Date:08-29-18 <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 />