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RECQR F <br /> ary 2006 <br /> Spill Bucket Testing Report Form Nov 2 9 X017 <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 lENVIRONoc rt <br /> 1.FACILITY INFORMATION <br /> Facility Name: TIWANA GAS -- Date of Testing: 6-26-17 <br /> Facility Address: 1210 E.HAMMER LANE STOCKTON, CA 95213 <br /> Facility Contact: PAUL Phone: 209-477-3111 <br /> Date Local Agency Was Notified of Testing:5/24/2016 <br /> Name of Local Agency Inspector(f present during testing): Elena <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <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 /> 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 El Contained in <br /> ®Contained in Sump ®Contained in Sump 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 I 1 11 <br /> Final Reading(RF): 3 11 1/2 14 <br /> Test Duration(TF—Ti): HR HR HR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: FAILED ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail <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 . r\ I <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 />