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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: 99 SHELL I Date of Testing: 9/24/09 <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 :9-10-09 _ <br /> Name of Local Agency Inspector(if present during testing): GARRET BACKUS <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. Nim-no ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® TCC 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 /> F] Direct Bury E] Direct Bury <br /> Bucket Installation Type: El Direct Bury F1 Direct Bury ® Contained in El Contained in <br /> ® Contained in Sump ® Contained in Sump Sump Sum <br /> Bucket Diameter: 1 1 11 11 <br /> Bucket Depth. 14 16 16 <br /> Wait time between applying - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 930 930 930 <br /> Initial Reading(R,): 13 1/2 15 1/2 15 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 13 1/2 15 1/2 15 <br /> Test Duration(TF—T,): HOUR HOUR HOUR <br /> Change in Reading(RF-R,): 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, and recommended follow-up for failed tests) <br /> NONE <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: Date: 9-24-09 <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 />