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� 3 S <br /> 7 5NVRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill conta d form and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for su ffipatory'agency. <br /> Xj <br /> 1. FACILITY INFORMATION <br /> Facility Name: SUPER STOP I Date of Testing: 4-29-14 <br /> Facility Address: 290 N MAIN STREET MANTECA CA <br /> Facility Contact: Mandeep Phone: <br /> Date Local Agency Was Notified of Testing:3-14-14 <br /> Name of Local Agency Inspector(f present during testing): ARIS <br /> 2.TESTING 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: H2O&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 /> ®Direct Bury ®Direct Bury <br /> ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in El Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 12 <br /> Wait time between applying NA NA NA NA <br /> vacuum/water and start of test, <br /> Test Start Time(Ti): 10 10 10 <br /> Initial Reading(Rj): 14 14 11 <br /> Test End Time(TF): 11 11 11 <br /> Final Reading(RF): 14 14 11 <br /> Test Duration(TF—TI): 1 HR 1 HR 1 HR <br /> Change in Reading(RF-Ri): 0 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result ® Pass ❑Fail ®;Pass ❑Fail 0 Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Flappers opw <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: TdkDate: 4-29-14 <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 />