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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MONTEREY FUEL I Date of Testing: 1/31/2018 <br /> Facility Address: 1001 E. YOSEMITE AVE MANTECA, CA 95336 ., . <br /> Facility Contact: Phone: 'T 13 1 xl <br /> Date Local Agency Was Notified of Testing:1/19/2018 <br /> Name of Local Agency Inspector(if present during testing): JOHN&ZUNA i i` "j, !' <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-01'12 Fax:(209)744-0116' <br /> Technician Conducting Test: ElEd Stearns ® Zane A.Nimmo E] David A.Winkler F] Felix G.Ramirez <br /> 8211269—UT 8211269-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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 13 7/8 14 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1227 1227 1227 <br /> Initial Reading(RI): 11 12 7/8 13 1/4 <br /> Test End Time(TF): 1327 1327 1327 <br /> Final Reading(RF): 11 12 7/8 13 1/4 <br /> Test Duration(TF—TI): HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail` ❑ Pass _ ❑Fail ® Pass ❑Fail ® Pass ❑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 /> 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: 1/31/2018 <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 />