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E <br /> kRx z'ti <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form RPR 12 2016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment str.,u�ture, . cncy. <br /> rm and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for subin <br /> 4 Y "Rl <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(if present during testing): FAHTIMA <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: ❑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 /> � u <br /> Identify Spill Bucket(By Tank 1 87 SLAVE 2 87 SYPHON 3 87 MAIN 4 91 OCTANE <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury El Direct Bury <br /> Bucket Installation Type: El Direct Bury El Direct Bury ®Contained in ®Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <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(Tj): 9 9 9 9 <br /> Initial Reading(RI): 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 /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑i 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 /> 'JS te laws and regulations do not current.01y require testing to be performed by a qualified contractor.However,local <br /> quirements may be more stringent. <br />