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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATInN <br />Facility Name: ESCALON MINI MART Date of Testing: 12-13-16 <br />Facility Address: 1097 E YOSEMITE BLVD ESCALON CA <br />Facility Contact: BILL I Phone: 209-838-1546 <br />Date Local Agency Was Notified of Testing :11-21-16 <br />Name of Local Agency Inspector (if present during testing): SJV FATINAH <br />2. TESTING C ONTR A C TnR INFnU X4 A •rrniv <br />Company Name: AFFORDA TEST 416 2°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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPIT.1, RIT'KF.T TF.CTINta INFnDX4Arrrniar <br />Test Method Used: ® Hydrostatic ❑ Vacuum v V z ❑Other , <br />Test Equipment Used: TAPE / <br />3 `iL <br />H2O <br />Equipment Resolution: 1/16 <br />� fi. ., ., a, ,,., y. F, £ :.:. n1,. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Y� z&" ..r, & ..-a' ., .✓s J , v ` N+. 9, ,,,.., <br />3 <br />1 87 2 91 <br />4 <br />Bucket Installation Type: <br />Di <br />Direct B <br />® Bury ®Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />El Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />12 12 <br />Bucket Depth: <br />14 14 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />- <br />Test Start Time (Ti): <br />1000 1000 <br />Initial Reading (RI): <br />14 14 <br />Test End Time (TF): <br />1100 1100 <br />Final Reading (RF): <br />14 14 <br />Test Duration (TF — TI): <br />1 HOUR 1 HOUR <br />Change in Reading (RF - RI): <br />0 0 <br />Pass/Fail Threshold or <br />Criteria: <br />- - <br />- <br />Test Result: <br />® Pass ❑ Fail ® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />comments — (include information on repairs made prior to testing and recommended follow up for failed tests) <br />®PW BUCKETS <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:fr____er_ <br />Date:12-13-16 <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 />