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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 /> Facility Name: MANTECA EXPRESS MART Date of Testing: 5/30/12 <br /> Facility Address: 419 S. MAIN STREET MANTECA, CA 95337 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/19/12 <br /> Name of Local Agency Inspector(f present during testing): MUNI <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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> FN <br /> dentify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> umber, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: ® Direct Bury ❑Direct Bury ❑ Contained in ❑Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sump Sum <br /> -1 <br /> ` Bucket Diameter: 11 1 l 11 i <br /> Bucket Depth. 15 15 15 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0945 0945 0945 <br /> Initial Reading(Ri): 13 3/4 14- 13 1/4 <br /> Test End Time(TF): 1045 1045 1045 <br /> Final Reading(RF): 13 3/4 14- 13 1/4 <br /> Test Duration(TF—Tj): HR HR HR HR <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, and recommended follow-up 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 Date: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local rcquirrmCni> <br /> may be more stringent. <br />