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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(if 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 I Date 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(if present during testing): GARRET BACKUS <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d 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(Bv Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc.) <br /> E]Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑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 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1515 1515 <br /> Initial Reading(Rj): 121/4 12 1/8 <br /> Test End Time(TF): 1615 1615 <br /> Final Reading(RF): 12 1/4 12 1/8 <br /> Test Duration(TF—Tj): HOUR 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 /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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 />