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A ens W� 3} s@uJ3te3 <br /> I..D <br /> ViI*,6B;glary 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containme "s. v 606rm and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the 1t3cAlztijency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: UNITED PACIFIC #5447 Date of Testing: 8-31-17 <br /> Facility Address: 1469 E HAMMER LANE STOCKTON CA 95210 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:8-1 &8-17 17 <br /> Name Of Local Agency Inspector(f present during testing): AARON <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 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-UT 8211269-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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 89 <br /> Number,Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: F]Contained in ❑Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 l 1 11 11 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: - - <br /> Test Start Time(Ti): 9 9 9 9 <br /> Initial Reading(R,) 12 12.50 12 12.50 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(RF): 12 12.50 12 12.50 <br /> Test Duration(TF—T,): 1 HR IHR IHR 1 HR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail- ®,Pass ❑ FaiIM Pass E3-Fail N 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: V '�I—j Date 8-31-17 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />