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11 <br />Ll <br />SWRCB, January 2006 <br />Spill Bucket 'Testing Report Form <br />This form is intendedfor use by contractors performing annual testing oj'UST spill containment structures. The completed form and <br />printouts front tests (if applicable), should be provided to the facility owner/operator for .submittal to the local regulatory agency. <br />I F A CTT .TTV TNF(1Q M A'T T(1N <br />Facility Name: TRACY VALERO Date of Testing: 9/5/13 <br />Facility Address: 2375 N. TRACY BLVD. _ mm - TRACY, CA 95377 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing :9/3/13 <br />Name of Local Agency Inspector (if present during testing): TWI <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"' 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 />Credentials': ® ICG Service Tech. Z SWRCB Tank Tester <br />Z CPTT:T, RITI"KF.T TF.6TINf: TNFnRMAT10N <br />Test Method Used: ® Hydrostatic ❑ Vacuum Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 89 <br />3 91 <br />4 <br />Bucket Installation Type: <br />Z Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in sump <br />® Direct Bury <br />❑ Contained in <br />Summa — <br />❑ Direct Bury <br />❑ Contained in <br />sump <br />Bucket Diameter: <br />I l <br />11 <br />I 1 <br />Bucket Depth: <br />12 3/4 <br />12 <br />12 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />0900 <br />0900 <br />0900 <br />Initial Reading (RI): <br />11 3/4 <br />10 3/4 <br />11 -- <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (RF): <br />11 3/4 <br />10 3/4 <br />11 -- <br />Test Duration (TF — Tj): <br />HR <br />HR <br />HR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Thresbold or <br />Criteria: <br />Test Result: <br />0 Pass ❑ Fail <br />® Pass [:]Fail <br />ER Pass ❑Fail <br />❑ Pass ❑ Faii <br />Comments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />CERTIFICATION OF TECIENICUN 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 www 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 />