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S WRCB,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: ABC FOODS MART Date of Testing: 4-25-13 <br /> Facility Address: 713 N EL DORADO STOCKTON CA <br /> Facility Contact: VIC Phone: <br /> Date Local Agency Was Notified of Testing A-9-13 <br /> Name of Local Agency Inspector(fpresent during testing): JEFF <br /> _ESTING 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) <br /> F1 Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ® Contained in El Contained in <br /> » ® Contained in Sump ® Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 14 17 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9 9 9 <br /> Initial Reading(RI): 14 13 16 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 1 13 16 <br /> Test Duration(TF—T,): 1 HR 1 HR 1 HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ❑ Pass ®Fail I ® Pass ❑ Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 87 BUCKET FAILED , Needs permit to replace. Retest after repairs <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: Vl�)—j Date 4-25-13 <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 />