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g <br /> Spill Bucket Testing Report Form <br /> SEP 19 201fi wRCB>January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill contai@Pq rE"j*completed form and <br /> printouts from tests(fapplicable), should be provided to the facility owner/operatorfgi�Wl� fid$ ,Wlatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 99 SHELL Date of Testing: 8-24-2016 <br /> Facility Address: 7700 MORELAND RD. STOCKTON, CA 95212 <br /> Facility Contact: ANGLE Phone: 209-957-5398 <br /> Date Local Agency Was Notified of Testing:7-27-16 <br /> Name of Local Agency Inspector(if present during testing): VICKI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"'Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo Zane A.Nimmo x 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, H 2 0 Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 2 4 <br /> Number, Stored Product, etc.) <br /> Ll Direct Bury F1 Direct Bury <br /> Bucket Installation Type: [I Direct Bury E]Direct Bury ®Contained in El Contained in <br /> ® Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: I l 11 11 <br /> Bucket Depth: 14 1/4 16 1/2 16 <br /> Wait time between applying - - <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9 9 9 <br /> Initial Reading(RI): 13.50 15 15 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 13.50 15 15 <br /> Test Duration(TF—Ti): HOUR HOUR HOUR <br /> Change in Reading(RF-Ri): 0 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, uncirecommended follow-up for failed tests) <br /> OPW <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 /> W <br /> Technician's Signature:_._ Date: 8-24-2016 <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 />