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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 /> 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: UNITED GAS IDate of Testing: 7/13/09 <br /> Facility Address: 440 W. CHARTER WAY STOCKTON,CA 95210 <br /> Facility Contact: NICK BOKIDES Phone: <br /> Date Local Agency Was Notified of Testing:7/9/09 <br /> Name of Local Agency Inspector(rf present during testing): GARRET BACKUS <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFCORDA 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 MEASURE, 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 El Bury <br /> ® Direct Bury ® Direct Bury ❑ Contained in ❑ Contained in <br /> Bucket Installation Type: ❑ Contained in Sump ❑Contained in SumpSum Sum <br /> Bucket Diameter: 1 1 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1515 1515 <br /> Initial Reading(Rj): 12 1/4 12 1/8 <br /> Test End Time(TF): 1615 1615 <br /> ong(RF): 12 1/4 12 1/8 <br /> n(TF-Tj): HOUR HOUR <br /> eading(RF-Rj): 0 0 <br /> reshold or __lt: ® Pass ❑ Fail 2 Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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: <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 />