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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: TIWANA GAS I Date of Testing: 6-26-17 <br /> Facility Address: 1210 E.HAMMER LANE STOCKTON, CA 95213 <br /> Facility Contact: PAUL I Phone: 209-477-3111 <br /> Date Local Agency Was Notified of Testing:5/24/2016 <br /> Name of Local Agency Inspector(tfpresent during testing): Elena DEC 0 4 �,y7 <br /> 2.TESTING CONTRACTOR INFORMATION N'1'AL��i1LALT <br /> Company Name: AFFORDA TEST 416 211 Street Galt,CA 95632 (209)744-011 J -!�W)n`}�4`M 16 <br /> Technician Conducting Test: ❑Ed Stearns ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G. Ramirez <br /> 8184188 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 /> Ell, f <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> ❑Direct Bury ❑ Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ® Contained in Sump ® Contained in Sump ® Contained in ElContained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 12 1/2 14 7/8 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10 10 10 <br /> Initial Reading(Ri): 12 11 1/2 14 <br /> Test End Time(TF): 11 11 I 1 <br /> Final Reading(RF): 3 11 1/2 14 <br /> Test Duration(TF—TI): HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: FAILI Pass'; ❑Fat1 N F «1s ❑ T ass, <br /> i�i1 ,,. " ❑.'Fait <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Repair and retest by others <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 /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local <br /> requirements may be more stringent. <br />