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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 . FACILITY INFORMATION <br /> Facility Name : JAMAR SVC Date of Testing : 05 - 17 - 18 <br /> Facility Address : 4075 EAST AMIN STREET STOCKTON CALIFORNIA <br /> Facility Contact: JASON Phone : 209-462-4685 <br /> Date Local Agency Was Notified of Testing : 04-25 - 18 <br /> Name of Local Agency Inspector (ifpresent during testing) , SAN JOAQUIN CO STACI <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : AFFORDA TEST 416 2°a Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G . Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials ' : ® ICC Service Tech. ® SWRCB Tank Tester <br /> I <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : TAPE H2O Equipment Resolution : 1 / 16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury F1 Direct Bury ❑ Direct Bury <br /> Bucket Installation Type : El Contained in <br /> ❑ Contained in Sump El Contained in Sump ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> l Test Start Time (TI): 1100 1000 <br /> i <br /> Initial Reading (RI) : 13 12 <br /> Test End Time (TF) : 1200 1000 <br /> Final Reading (RF) : 13 12 <br /> Test Duration (TF — Tj) : 1 HOUR 1 HOUR <br /> Change in Reading (RF - RI) : 0 0 <br /> Pass/Fail Threshold or0 0 0 0 <br /> Criteria: <br /> Test Result. ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and f•ecommended follow-up for fiailed Pests) <br /> OPW BUKCETS <br /> ALL BUCKETS HOLD 5 GALLON CAPACITY <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 : 05 - 17- 18 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> i may be more stringent. <br /> I <br />