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I <br />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 Ti A !`77 iTSI iNTi (li2M A TTnN <br />Facility Name: STOCKTON AUTO CENTER CA. CAR WASH Date of Testing: 6/25/09 <br />Facility Address: 3434 E. HAMMER LANE STOCKTON, CA 95212 <br />Facility Contact: CHRIS B. <br />Phone: 209-956-4040 <br />Date Local Agency Was Notified of Testing :6/11/09 <br />Name of Local Agency Inspector (ifpresent during testing): GARRET BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester B <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />1 87 <br />❑ Direct Bury <br />®Contained in Sump <br />2 91 <br />❑ Direct Bury <br />®Contained in Sump <br />3 DIESEL <br />❑ Direct Bury <br />Contained in <br />Sump <br />4 <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type:® <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />133/4 <br />141/2 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />------- <br />-------- <br />-------- <br />Test Start Time (Ti): <br />950A <br />950A <br />950A <br />Initial Reading (RI): <br />13- <br />13 5/8 <br />13 <br />Test End Time (TF): <br />1050 <br />1050 <br />1050 <br />Final Reading (RF): <br />13 <br />135/8 <br />13 <br />Test Duration (TF — TI): <br />HOUR <br />HOUR <br />HOUR <br />Change in Reading (RF - RI): <br />NONE <br />NONE <br />NONE <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />1A 7 <br />xs$ . . Flit'... .. . bass ©Fiiil ., Pass Cj )al ❑'sss ❑ 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: <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 />S <br />