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e <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: GASLO - SINCLAIR I Date of T -1 " , <br /> Facility Address: 7906 N. EL DORADO ST. STOCKTON, CA 95210 ° =� <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 3-2-17 / ,7 <br /> Name of Local Agency Inspector(if present during testing): VICKI <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONMENTAL i `iENI_ , <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-011 ax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns Zane A.Nimmo M David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': M ICC Service Tech. M SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: M Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <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 ❑Direct Bury E]Direct Bury F1 Direct Bury <br /> Bucket Installation Type: M Contained in Sump M Contained in Sump M Contained in M Contained in <br /> 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(Ti): 9 9 9 9 <br /> Initial Reading(Ri): 13 13 13 13 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(RF): 13 13 13 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: M 'Pass ❑Fait M Pass ❑Fail I Z Pass ❑Fail M Pass ❑;Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW <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:3-28-17 <br /> ' State laws and regulations do not current.01y require testing to be performed by a qualified contractor.However,local <br /> requirements may be more stringent. <br />