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i� . 6 9 <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.FACILITY INFORMATION <br /> Facility Name: KNIFE RIVER I Date of Testing: _.,7/12.116, <br /> Facility Address: 655 W. CLAY ST STOCKTON,CA <br /> Facility Contact: RODGER Phone: <br /> Date Local Agency Was Notified of Testing:6-27-16 <br /> Name of Local Agency Inspector(rf present during testing): � g <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician: ®Ed Steams ❑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 /> F <br /> Identify Spill Bucket(By Tank 1 87 2 DIE 3 4 <br /> Number, Stored Product, etc.) 11 1 <br /> ®Direct Bury ®Direct Bury ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑ Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 1/2 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 130 130 <br /> Initial Reading(Rj): 121/2 13 <br /> Test End Time(TF): 230 230 <br /> Final Reading(RF): 12 1/2 13 <br /> Test Duration(TF—TI): IHR IHR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Tet, esit• < C1 �► _ ❑ F Fay ❑ ❑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 /> ,, 0----- <br /> Technician's Signature: 1f y = Date:7/12/16 <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 />