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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: Country Club Circle K Date of Testing: 1-23-17 <br /> Facility Address: 2575 COUNTRY CLUB BLVD STOCKTON CA 95204 <br /> Facility Contact: DAVE HINDS Phone: 209-932-11071 <br /> Date Local Agency Was Notified of Testing:12-27-16 <br /> Name of Local Agency Inspector(ifpresent during testing: FEES <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-01 4- <br /> Technician Conducting Test: ❑Lyle D.Nimmo F-1ZaneA.Nimmo ® David A.Winkler E] 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 DIE 4 <br /> Number, 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 SumpSum <br /> Bucket Diameter: 11 11 I I <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying _ _ - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 12 12 12 <br /> Initial Reading(RI): 13 10 10 <br /> Test End Time(TF): 1 1 1 <br /> Final Reading(RF): 13 10 10 <br /> Test Duration(TF—Ti): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or _ _ _ <br /> Criteria <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> PHIL TITE BUCKETS. 91 AND DSL BUCKETS NOT 5 GAL . TEST PASSED. <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:01-29-16 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However, <br /> local requirements may be more stringent. <br />