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V <br /> 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(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: NATIONAL PETROLEUM Date of Testing: 05-02-14 <br /> Facility Address: 713 N EL DORADO ST STOCKTON CA mmint—m 11= <br /> Facility Contact: ARSHID I Phone: 209-465-5f4 r.%j C.-I V L-D-- <br /> Date Local Agency Was Notified of Testing:04-25-14 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO TWEEE <br /> 2.TESTING CONTRACTOR INFORMATION FNVIR MENTAL <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)7441896 W: )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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury E] Direct Bury <br /> Bucket Installation Type: ® Contained in El Contained in <br /> � ® Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 1 1 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 935 935 935 <br /> Initial Reading(Rj): 13 13 13 <br /> Test End Time(TF): 1035 1035 1035 <br /> Final Reading(RF): 13 13 13 <br /> Test Duration(TF 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 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 /> OPW BUCKETS <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:05-02-14 <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 />