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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This jor•m is intended.for•use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouls•Ji•orn tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agenc:r. <br /> 1. FACII.ITY INFORMATION <br /> Facility Name: MANTECA ARCO I Date of Testing: 3/28/11 <br /> Facility Address: 1711 E. YOSEMITE AVE MANTECA, CA 95336 <br /> Facility Contact: DEEPA Phone: _ <br /> Date Local Agency Was Notified of Testing:3/14/11 <br /> Name of Local Agency Inspector(if present during testing): DEEPA <br /> _ 2. TESTIN_ G CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209) 744-0112 Fax: (209)744-0116 II <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. inkler ❑ 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 _ ^I <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc.) <br /> El Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: <br /> El Direct Bury Direct Bury ® Contained in ❑ Contained in <br /> ® Contained in Sump ® Contained in Sump SumpSum <br /> Bucket Diameter: 1 1 1 I 11 <br /> Bucket Depth: 14 14 13 _ <br /> Wait time between applying __ <br /> vacuum/water and start of test: - <br /> Test Start Time(Ti): 1210 1210 1210 <br /> Initial Reading(Rj): 13 12 3/4 11 1/2 <br /> Test End Time(TF): 1310 1310 1310 <br /> Final Reading(RF): 13 12 3/4 11 1/2 <br /> Test Duration(TF—Ti): 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: e Date: 3/28/11 <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 />