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R E Cg(V <br />'Ep2006 <br />Spill Bucket Testing Report Form FE3. 0 5 2014 <br />Thisform is intendedfor use by contractors performing annual testing of USTspill containment s coMDl redform and <br />omp <br />Printoutsfrom tests (if applicable), should be provided to thefacility ownerloperatorfor submitta rohsiaaf, At cy. <br />U <br />C -F.79 -1-W A fi <br />IrYlll HEALTH DEPARTMENT <br />Facility Name: TRACY VALERO Date of Testing: 10-07-13 <br />Facility Address: 2375 TRACY BLVD TRACY CA <br />Facility Contact: HAKAM 09-835-5358 <br />Date Local Agency Was Notified of Testing :09-03-13 <br />Name of Local Agency Inspector (ii(present during testing): SAN JOAQUIN CO Thuy <br />2. TESTING CONTRACTOR INFORMATIrON <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: Lyle D. Nimmo [I Zane A. Nimmo Z David A. Winkler Z Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': U ICC Service Tech. SWRCB Tank Tester <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: 10107-13 <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 />3. SPILL BUCKET TESTING INFORMATION <br />Nil <br />Equipment Resolution: <br />1/16 <br />P_ <br />7117111-1,11 <br />96 - <br />.7 <br />Bucket Installation Type:- <br />Z Direct Bury <br />Contained in Sump <br />Z DBury <br />■ Contained in S <br />J <br />lir irect B ury <br />D Contained in <br />S p <br />■Directirect Bury <br />Contained in <br />Sum <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time b;iWeen apply ing <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />Initial Reading (Rj): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF -- Tj): <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />4 31� a <br />WIN <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: 10107-13 <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 />