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9 9 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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: MEL BOKIDES ARCO Date of Testing: 05-18-10 <br />Facility Address: 444 MOSSDALE RD LATHROP CA <br />Facility Contact:Phone: <br />Date Local Agency Was Notified of Testing :4-26-10 <br />Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO. TWEE <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: El Lyle D. NimmoEl Zane A. Nimmo [:1 David A. Winkler Z Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />� Credentials': E ICC Service Tech. Z SWRCB Tank Tester I <br />Test Method Used: Z Hydrostatic El Vacuum El Other <br />Test Equipment Used: TAPE / 1420 <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type- <br />Z Direct Bury <br />El Contained in Sump <br />Z Direct Bury <br />El Contained in Sump <br />Z Direct Bury <br />F-1 Contained in <br />Sump <br />F] Direct Bury <br />Ej Contained in <br />Sump <br />Bucket Diameter: <br />11 <br />11 <br />12 <br />Bucket Depth: <br />11 <br />12 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />1200 <br />1200 <br />1200 <br />Initial Reading (RI): <br />10 <br />11 <br />13 <br />Test End Time (TF): <br />1300 <br />1300 <br />1300 <br />Final Reading (R,): <br />10 <br />11 <br />13 <br />Test Duration (TF — TI): <br />I HOUR <br />I HOUR <br />I HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />L Z Pass El Fail <br />Z Pass El Fail <br />Z Pass El Fail <br />El Pass El Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />Technician's Signature: Date: <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 />