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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 /> EFacility <br /> y Name: 99 SHELL <br /> Date of Testing: 08-10-10 <br /> ty Address: 7700 MORELAND RD STOCKTON CA Contact: ANGLE Phone: _ <br /> Date Local Agency Was Notified of Testing: ----- <br /> GARRETT SAN JOAQUIN CO <br /> Name of Local Agency Inspector(if present during testing): - <br /> 2. TESTING CONTRACTOR INFORMATION _ <br /> 209 744-0112 Fax:(209)744-0116 <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 ( ) <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo E] 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 /> Y <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other =-I <br /> Equipment Resolution: 1/16 <br /> Test Equipment Used: TAPE/H2O _ <br /> Identify Spill Bucket(By Tank 1 87 <br /> 2 91 T=D E 4 <br /> Number, Stored Product, etc.) ❑ Direct Bury ❑ Direct Bury <br /> ❑ Direct Bury ❑ Direct Bury ®Contained in ❑Contained in <br /> Bucket Installation Type: ® Contained in Sump ® Contained in Sump SumpSump _- <br /> Bucket Diameter: <br /> Bucket Depth: 141/2 16 15 _._-... <br /> Wait time between applying - - - <br /> vacuum/water and start of test: 930 <br /> Test Start Time(T,): 930 930 <br /> Initial Reading(R,): <br /> 123/4 141/2 133/4 <br /> Test End Time(TF): <br /> 1030 1030 1030 <br /> Final Reading(RF): <br /> 123/4 141/2 133/4 <br /> HOUR 1 HOUR <br /> Test Duration(TF—T,): I HOUR 1 - <br /> Change in Reading(RF-R,): <br /> 0 0 0 __ I <br /> Pass/Fail Threshold or _ - - _ <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail s <br /> ® Pass Fail ® Pass ❑ Fail ❑ Pas ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-zip for failed tests) <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: <br /> Date:8/10/10 <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 />