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Rrj6EIVED <br />JAN 0 5 2018 SWRCB, January 2006 <br />Spill Bucket Testing Report Fo�vfRoErA <br />This form is intended for use by contractors performing annual testing of UST spill cont tf completed form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submitta o h cal regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ESCALON MINI MART <br />Date of Testing: 12-13-17 <br />Facility Address: 1097 YOSEMITE AVE ESCALON CA <br />Pt „ l <br />Facility Contact: <br />Phone: 209-838-15 ,'y - _ 'A <br />Date Local Agency Was Notified of Testing :11-22-17 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Name of Local Agency Inspector (af present during testing): <br />1AN TO <br />SAN JAOQUIN CO two <br />2. TESTING CONTRACTOR INFORMATION E T <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 F (2�,7fJ6 <br />Technician Conducting Test: ❑Ed Sterns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />814188 -UT 8211269 -UT 5263373 -UT 5273934 -UT <br />N Credentials': ❑ ICC Service Tech. ❑ SWRCB Tank Tester I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / <br />H2O Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 3 <br />4 <br />Bucket Installation Type:El <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury ❑ Direct Bury <br />Contained in <br />El Contained in Sump Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />I 1 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />945 <br />945 <br />Initial Reading (RI): <br />12 <br />12 <br />Test End Time (TF): <br />1045 <br />1045 <br />Final Reading (RF): <br />12 <br />12 <br />Test Duration (TF — TI): <br />1 HOUR <br />I HOUR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />0Pass ' ❑ <br />Fail Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITS 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: 12-13-17 <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 />