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y SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended fbr 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 /> Facility Name: MANTECA EXPRESS Date of Testing: 5-14-13 <br /> Facility Address: 419 S MAIN STREET MANTECA CA <br /> Facility Contact: BOBBY Phone: 209-239-7978 <br /> Date Local Agency Was Notified of Testing A-16-13 <br /> Name of Local Agency Inspector(f present during testing): THUY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d 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: H2O&TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket (fay Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury [-I Contained in El Contained in <br /> ❑Contained in Sump E:1 Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 15.50 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10 10 10 <br /> Initial Reading(Rj): 14 15 15.50 <br /> Test End Time(TF): 1 1 11 I 1 <br /> Final Reading(RF): 14 15 15.50 <br /> Test Duration(TF-Tj): 1 HR 1 HR I HR <br /> Change in Reading(RF-Ri): 0 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <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 /> PHIL TITE FLAPPERS <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: Tc--�—j Date 5-14-2013 <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 />