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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 />I OIsrY11 wh-ri 101 -TI : ►7 7 i1�iY CIT►i <br />Facility Name: EL DORADO FOOD SHELL I Date of Testing: 02-21-17 <br />Facility Address: 2320 NORTH EL DORADO BLVD STOCKTON CALIFORNIA 95204 <br />Facility Contact: BOB Phone: 209-943-1311 <br />Date Local Agency Was Notified of Testing :02-09-17 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO ALAINA <br />ir4r Y 9G`11 Y I�[!`�KI]►`Y Y7_� IYTT1177i�9T1 ; ►� i ►1 <br />Company Name: AFFORDA TEST 416 2"d 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': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPIT,T, RITCKF,T TFSTING INFnRMATInN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />El Direct Bury <br />❑ 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 (Ti): <br />1 921 <br />921 <br />921 <br />1 <br />Initial Reading (RI): <br />121/4 <br />121/4 <br />13 <br />u Rpt <br />Test End Time (TF): <br />1021 <br />1021 <br />1021 <br />Final Reading (RF): <br />12/14 <br />121/4 <br />13 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />ENVIRONMENTAL <br />0 <br />HEA <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />DEPARTMENT <br />0 <br />Test Result: <br />® Pass ❑ Fail <br />®"Pass ❑ Fail ` <br />M Pass ; ❑ Fail <br />❑ Pass ❑ Fail .. <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />BUCKETS CHECKED FOR 5 GALLON CAPACITY. PASSED <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: <br />Date: <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 />I <br />