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Spill Bucket Testing Report Form SWRCB,January 2006 <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 FOOD MART Date of Testing: 4-25-12 <br /> Facility Address: 713 N. ELDORADO ST. STOCKTON, CA 95202 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:3/22/12 <br /> Name of Local Agency Inspector(fpresent during testing): JEFF WONG <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.Nimmo ® Zane A.Nimmo ❑ David A. Wink er ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials . 0 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 /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Ntrnaber, StoredProduct, etc.) <br /> ❑Direct Bury ❑ Direct Bury ❑Direct Bu ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in ® Contained in <br /> ® Contained in Sump ❑Contained in Sump <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 1/2 13 1/2 17 <br /> Wait time between applying _ <br /> vacuum/water and start of test: -- <br /> Test Start Time(Tt): 1340 1340 1340 <br /> Initial Reading(Rj): 12 3/4 12 5/8 15 <br /> Test End Time(TF): 1440 1440 1440 <br /> Final Reading(RF): 12 3/4 12 5/8 15 <br /> Test Duration(TF—Tt): HR HR HR HR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1�z <br /> -" -- -- <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 requirements <br /> may be more stringent. <br />