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4CEIVED <br />J A `SI)a7nuary 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containme t cWLEALTH <br />orm and <br />printoutsfrom tests (ifapplicable), should be provided to the facility owner/operatorfor submittal to th ency. <br />1. FACILITY INFORMATION <br />Facility Name: ESCALON MINI MART I Date of Testing: 12-13-16 <br />Facility Address: 1097 E YOSEMITE BLVD ESCALON CA <br />Facility Contact: BILL 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 CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"a Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler E Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />II Credentials': E ICC Service Tech. E SWRCB Tank Tester I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 4 <br />Bucket Installation Type: <br />E Direct Bury <br />❑ Contained in Sump <br />E Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury ❑ Direct Bury <br />❑ Contained in ❑ Contained in <br />Sump Sum <br />Bucket Diameter: <br />12 <br />12 <br />Bucket Depth.. <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1000 <br />1000 <br />Initial Reading (Ri): <br />14 <br />14 <br />Test End Time (TF): <br />1100 <br />1100 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF — Tj): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />-Test Result: <br />E Pass ❑ Fail <br />E Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW 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: 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 />