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Ur/vy/Zvi v rtcl 1v: 49 rAX ZVJ4bt$i43s bic Ehu --+-• Azzoroazest 1Qjuv1/vvl <br />SWRCB, January 2006 <br />Spill Bucket Testing Deport Form <br />This form is intended for use by contractors performing annual testing of UST spill containment strucilrres. The complexed form (IrUl <br />printouts fi-om tests (if applicable), should be provided to the facility owner/operator for submittal to tY?e local regulatory agenc,� <br />1. r<ACTLITY INFORMATION _ <br />facility Name: STOCKTON AUTOMALL CAR WASH 76 Date of Testing: 6-23-2010 <br />Facility Address: 3434E HAMMER LN STOCKTON CA __..._.___....�I <br />Facility Contact: CHRIS Phone: __------ <br />.-•' <br />Date Local Agency Was Notified of Testing: _ € <br />Name of Local A-Rency Inspector (if present during tearing): GARRET <br />Company Name: AFFORDA TEST 416 2id Street Galt, CA 95632 (209) 74470112 Fax: (209) 744-0116 2 <br />51 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo N David A. Winkler [ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT " <br />Credentialsl: Z ICC Service'rech. ® SWRCB Tank'rester <br />•t ..`TPTT.T . T11iiiC1V.1M'A'T Y0lV <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br />Identify Spill Bucket (B), Tank 1 87 2 91 3 ASL 4 <br />mber, .Stored Product, etc. <br />Number, �•.,` <br />.. ...I <br />❑ Direct Bury Direct Bury <br />❑ Direct Bury [D Direct Bury in <br />Bucket Installation Type: ontained in F1 <br />Sump pontained <br />®Contained in Sump 0Contained in Sump <br />I <br />Bucket Diameter: <br />11 <br />I I 1 1 <br />Bucket Depth: <br />13.50 <br />I4.50 14 <br />�� { <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />9 <br />9 9 <br />j <br />Initial Reading (Rj): <br />12 <br />13 13 <br />r <br />Test End Time (Tr): <br />10 <br />10 10 <br />Final Reading (Rlz): <br />12 <br />I3 13 <br />Test Duration (Ti: —"Fl): <br />IHR <br />IHR IHR <br />Change in Reading (Rl-- Rt): <br />0 <br />0 0 <br />-.__.._. <br />Pass/Fail Threshold or <br />1/16 <br />I/IG 1/I6 <br />Criteria: <br />Test Result: - <br />Pass ❑ I{ail 1 <br />2 Pass ❑ Tai1 1 ® Pass ❑ Fai1 <br />❑ Pass ❑ mail <br />Coininents -- (include information on repairs made prior to testing, and recomnrendedfollow-atp for fulled tesls) <br />CERTIFICA'T'ION OFTECHNICIAN RESPONSIBLE FOR C:Oil''DIJC7'IN1G'1'EiIS'1'isS'r1NG '�-- <br />t hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature; ��1 �� Date 6-23-2010 <br />'State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />inay be more stringent. <br />L000/L0001A XVd 9E:0T 0T0Z/CT/L0 <br />