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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMA <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 <br />Technician Conducting Test: ® David A. Winkler <br />5263373 -UT <br />Credentials': ®ICC Service Tech. ®SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />OCT't�2018 <br />ENTAL <br />DEPARTM <br />116 <br />Test Method Used: ®Hydrostatic <br />1:1 Vacuum E] Other <br />Facility Name: <br />Facility Address: <br />CHARTER WAY SHELL Date of Testing: 11-20-17 <br />620 WEST CHARTER WAY STOCKTON CA <br />Facility Contact: <br />Sukhi <br />Phone: 466-1901 <br />Date Local Agency Was Notified of Testing :10/25/17 <br />Name of Local Agency <br />Inspector (f present during testing): CECAR <br />2. TESTING CONTRACTOR INFORMA <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 <br />Technician Conducting Test: ® David A. Winkler <br />5263373 -UT <br />Credentials': ®ICC Service Tech. ®SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />OCT't�2018 <br />ENTAL <br />DEPARTM <br />116 <br />Comments — (include information on repairs made prior to testing and recommended follotiv-up for failed tests) <br />HAD TO RETEST 87 BUCKETS AFTER FIXING FILL ADAPTER <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: VG "j <br />'State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />maybe more stringent. <br />Test Method Used: ®Hydrostatic <br />1:1 Vacuum E] Other <br />Test Equipment Used: h20 and tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Installation Type: <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth. <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />2 <br />1 <br />1 <br />Initial Reading (Rj): <br />12 <br />11.50 <br />12 <br />Test End Time (TF): <br />3 <br />2 <br />2 <br />Final Reading (RF): <br />12 <br />11.50 <br />12 <br />Test Duration (TF — Ti): <br />1HR <br />IHR <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing and recommended follotiv-up for failed tests) <br />HAD TO RETEST 87 BUCKETS AFTER FIXING FILL ADAPTER <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: VG "j <br />'State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />maybe more stringent. <br />