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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: DELTA ARCO Date of l'esting: 7/28/11 <br /> Facility Address: 440 W. CHARTER WAY STOCKTON, CA 95206 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:7/28/11 <br /> Name of Local Agency Inspector(if present during lesling): JEFF WONG <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 /> "lest Mcthod Used: ®Hydrostatic ❑Vacuum ❑Other <br /> -fest Equipment Used: TAPE MEASURE, 1120 Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 1 87 2 3 91 4 <br /> Number, Stored Product, etc.) <br /> Dirccl Bury ❑ Direct Bun <br /> Bucket Installation Type: ® Direct Bury E] L]Direct Bury Contained in ❑Contained in <br /> yp [IContained in Sump ❑Contained in Sump <br /> SumpSum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 1/2 13 1/4 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 0955 0915 <br /> Initial Reading(Rt): 12 1/2 12 1/4 <br /> Test End Time(TF): 1055 1015 <br /> Final Reading(RF): 12 1/2 12 1/4 <br /> Test Duration(TF—Tt): HR I I R HR I I R <br /> Change in Reading(RF-Rt): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Com ments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 87 SPILL LEAKED AT FIRST TEST. FILL ADAPTER, 6 INCH NIPPLE, & <br /> JACK SCREW KIT WERE ALL LOOSE. I TIGHTENED EVERYTHING & <br /> TESTED BUCKET. PASS. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TI I IS 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: 7/28/11 <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 />