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e <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SAN JOAQUIN COUNTY JAIL Date of Testing: 11/15/16 <br /> Facility Address: 7000 MICHAEL CANLISS STOCKTON CA 95231 <br /> Facility Contact: JESSE Phone: <br /> Date Local Agency Was Notified of Testing:11/20/16 2 2016 <br /> Name of Local Agency Inspector(f present during testing): VICKIE <br /> 2.TESTING CONTRACTOR INFORMATIO HEALTH <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-V -9-0116 <br /> Technician: ®Ed Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-UT 5249115-UT 5263322-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 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 DIESEL N 2 DIESEL S 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ElContained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 93/4 113/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1400 1400 <br /> Initial Reading(Rj): 93/4 113/4 <br /> Test End Time(TF): 1500 1500 <br /> Final Reading(RF): 93/4 113/4 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result ED`Pass ❑Fair [9 Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fait <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: °r{" = Date:l l/15/16 <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 />