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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 /> Facilit 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: 209-6014312 <br /> Date Local Agency Was Notified of Testing:7-23-10 @7:47 <br /> Name of Local Agency inspector,(!(present during testing): RAY .:.� <br /> 2,TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 M Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ®Lyle D.Nimmo E3 Zane A.Nimmo [I David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: 0 ICG Service Tech. JE SWRCB Tank Tester <br /> 3. SPILL 13UCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑Vacuum ❑ Other <br /> � <br /> Test Equipment Used: 1420/TAPE Equipment Resolution: 1/32" - <br /> Identify Spill Bucket(By Tank I RUL(87) 2 SUP(91) 3 4 <br /> Number, Stored Product, etc. <br /> 7 17 Direct Bury Direct[Bury <br /> ® Direct Bury ®Direct Bury ❑Contained in E]Contained in <br /> Bucket installation Type. ❑Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: I 1 - <br /> Bucket Depth: 13 13 <br /> Wait time between applying 0 0 <br /> vacuuni/water and start of test: <br /> Test Start Time(Ti): 1045 0900 �- <br /> Initial Reading(R,): <br /> _F2 1/4' 12" <br /> Test End Time(Tr): 1145 1000 <br /> Final Reading(RF): 12 1/4" 12" - <br /> - Test Duration(Tp— 0: t -- <br /> 0 <br /> Change in Reading(Rr-R,): 0 �.. <br /> Pass[Fail Threshold or 10 10 <br /> Criteria; <br /> Test Result: Pass Fail ❑ Pass © Fail <br /> � Pass ❑Fall ''�F>�s .,;�- 'Fail ❑ ❑.. _... <br /> !d tests) <br /> Comments_ (include information on D repairs <br /> NSTALLEDrPLUG.and CAP BAD eREMOVED AND INSTALLED 1NFLATIBLF.. <br /> 87 THE DRAIN WAS BAD, REMOVED A �^ <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�R__14 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 />