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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: DELTA ARCO I Date of Testing: 7/27/10 _ <br /> Facility Address: 440 CHARTER WAY STOCKTON CA 95210 <br /> Facility Contact: MAJOR SINGH I Phone: 209-601-4312 <br /> Date Local Agency Was Notified of Testing:7-23-10 @7:47 _ <br /> Name of Local Agency Inspector(if present during testing): RAY <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 ❑ 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: H20/TAPE Equipment Resolution: 1/32" J <br /> Identify Spill Bucket (By Tank I RUL(87) 2 SUP (91) 3 4 _ <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ® Direct BuryDirect Bury ❑ Direct Bury <br /> Bucket Installation Type: ElContained in Sump [jContained in Sump ❑ Contained in ❑ Contained in <br /> Sump Sum _ <br /> Bucket Diameter: i l 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1045 0900 _ <br /> Initial Reading(Ri): 12 1/4" 12" <br /> Test End Time(TF): 1145 1000 <br /> Final Reading(RF): 12 1/4" 12" _ <br /> Test Duration(TF—Ti): I HR 1 HR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or 10 IO <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) _s <br /> 87 THE DRAIN WAS BAD. REMOVED AND INSTALLED PLUG. CAP BAD REMOVED AND INSTALLED INFLATIBLI.: <br /> PLUG. <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: °`4` �/ Date: 7/27/10 <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 />