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FEB -16-2016 01:54P FROM: :4683433 P.8/8 <br />0 14E GEOVED ,a 0 J } <br />a 8 <br />FEB 1 C B, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containVWfiM1;A1fPrm and <br />printouts from tests ({f applicable), should be provided to the facility owner/operator for subm J4 agency. <br />1. FACILITY INFORMATION <br />Facilit Name: EL DORADO FOOD SHELL I Date of Testing: 02-12-13 <br />Facility Address: 2320 NORTH EL DORADO BLVD STOCKTON CALIFORNIA95204 <br />Facility Contact: BOB Phone: 209-943-1311 <br />Date Local Agency Was Notified of Testing :1-16-13 <br />Name of Local Agency Inspector (af present during testing): SAN JOAOUIN CO STACI <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 Conducting Test: ® Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': 0 ICC Service Tech. ® SWRCB Tank Tester <br />3_ C1111T.T. RTTt VR..T •rFcgrmrr_ INWIRMATTMa <br />Test Method Used: <br />H drostatic <br />❑ Vacuurn <br />--Other <br />Test Equipment Used: TAPE H2O <br />.1,111 MIN <br />Equipment Resolution: <br />1116 <br />r., <br />Identify Spill Bucket (By Tank <br />Number Stored Product, etc. <br />Bucket Installation Type: <br />1 87 <br />9 Direct Bury <br />❑ Contained in Sump <br />2 91 <br />® Direct Bury <br />❑ Contained in Sump <br />3 DIE <br />Direct Bury <br />Contained in <br />Sump <br />4 <br />Direct Bury <br />0 Contained in <br />Sum <br />Bucket Diameter, <br />11 <br />11 <br />11 <br />Bucket Depth: <br />14 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T,): <br />1030 <br />900 <br />1000 <br />Initial Reading (R,): <br />13 <br />12 <br />12 <br />Test .End Time (Tp): <br />1130 <br />1000 <br />1100 <br />Final Reading (RF): <br />13 <br />12 <br />12 <br />Test Duration (TF — Tj): <br />1 HOUR <br />1 HOUR <br />i HOUR <br />Change in Reading (RF- 114): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria <br />0 <br />0 <br />0 <br />Test Result: <br />Pas ❑ Fail <br />® Pass ❑ Fall <br />rags ®Fail <br />® Pass ❑ Fail <br />Comments -- include information on repairs made rior to testi and recommended allow -u or ailed Is <br />CHANGED SWIVEL ADAFTOR. ON 87 <br />()PW BUCKETS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained In this report is true, accurate, and in full compliance with legal requirements. <br />fy�, <br />Technician's Signature: - Date: 2-12-13 <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 />