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I <br /> I <br /> AUGSWRCBu IJanuary 2006 <br /> -Spill Bucket Testing Report Form tw�� �.1 i. <br /> This form is intended for use by contractors performing annual testing of UST spill containment strzictures. The completed form and <br /> printouts from tests(f applicable), 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: 8-9-2016 <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:7-21-16 <br /> Name of Local Agency Inspector(f present during testing): ELANA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"1 Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo Zane A.Nimmo X 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 <br /> therTest Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 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 /> El Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 1/4 13 - <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 930 930 <br /> Initial Reading(Ri): 12.50 12 <br /> Test End Time(TF): 1030 1030 <br /> Final Reading(RF): 12.50 12 <br /> Test Duration(TF—Ti): HR HR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Cont ments—(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 /> Te hnician's Signature: Date: 8-9-2016 <br /> tate laws and regulations do not currently require testing to be performed by a qualified contractor.However,local <br /> requirements may be more stringent. <br />