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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: GASLO - SINCLAIR Date of Testing: 3-21-2016 <br /> Facility Address: 7906 N. EL DORADO ST. STOCKTON, CA 95210 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing 2-18-16 <br /> Name of Local Agency Inspector(f present during testing): FAHTIMA <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 X 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. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> entify Spill Bucket(By Tank 1 87 SLAVE 2 87 SYPHON 3 87 MAIN 4 91 OCTANE <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑ Direct Bury ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ® Contained in ®Contained in <br /> ®Contained in Sump ® Contained in Sump Sump Sum <br /> k <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 14 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: -- <br /> Test Start Time(Ti): 9 9 9 9 <br /> Initial Reading(Rj): 12 13 12 1/8 13 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(RF): 12 13 12 1/8 13 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- <br /> TestResult: Z Pass ❑Fail Z Pass ❑Fail ® Pass ❑ Fail Pass ❑Fail <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 /> Technician's Signature . Date: 3-21-16 <br /> ' S ate laws and regulations do not current.01y require testing to be performed by a qualified contractor.However, local <br /> equirements may be more stringent. <br />