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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: KNIFE RIVER DSS I Date of Testing: 07-14-17 <br /> Facility Address: 655 WEST CLAY AVE STOCKTON CALIFORNIA 95206 <br /> Facility Contact: JOHN Phone: 209-948-0302 <br /> Date Local Agency Was Notified of Testing:06-26-17 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO CEASER <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2n1 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 /> 8184188 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 H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 11 1 87 2 DIE 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: F-1 Contained in El Contained in <br /> El Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: _ Rtk, <br /> - 1 <br /> Test Start Time(Ti): 900 900 <br /> Initial Reading(Ri): 13 1/2 13 1/2 <br /> Test End Time(TF): 1000 1000 NEA <br /> Final Reading(RF): 13 1/2 13 1/2 ENVIRON3 'L <br /> Test Duration(TF-Ti): 1 HOUR 1 HOUR DEPARTMENT <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 0 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 recommended follow-up for failed tests) <br /> OPW BUCKETS <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: 7-14-17 <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 />