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I 1 0 <br />SWRC8. January 2006 <br />Spill Bucket Testing Report Form <br />Thisfiorm is intended for use ky conlracfors performing ononral testing of 11.0 shill containment structures. The completed form and <br />pritzinvisfrom tests (if applicable). shovid he provided to Mejacilky o%L,nei-loperaturforvitbiaiiiiaI io the local regulatoij- agenq <br />1. FACILITY INFORMATION <br />Facility Nanit!: UNITED PACIFIC V5446 - JIFFY LUBE <br />Facility Address-, 1403 COUNTRY CLUB STOCKTON CA 95204 D�tc of Testing: 5-19-17 <br />Facility Contact: <br />Date Local Agency Was Notified of Testing :5-10-17 <br />Name of Local Agency Inspector Ofpresem Lring teit—iolg): Siv <br />2. TESTING CONTItACTOR NFORMATION <br />Company Name: AFFORDA TEST 416 2"d Street Gait, CA 95632 (209) 744-0112 Fax, (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Steams El Zane A. Nimmo & David A. Winkler [:] Felix G, Ratnirez <br />3184188 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': 0 ICC Service Tech, SWRCR Tank Tester <br />3. SPILI, BUCKET TESTING INFORNIATION <br />Test Equipment Used: h20 and tape measure ]-Equipment <br />ldentif}, Spill buck"6%? Tank I OIL-- 2 <br />Number,.Rored C1, etc:) <br />0 Direct Bury Direct Bury <br />Bucket InstalInnon Type: Contained in Sump C1 Contained in Sump <br />M <br />. .......... <br />Resolution- 1/16 <br />3 4 <br />-cB <br />ElDire0 Con, dury in Direct Bu.ry <br />❑C3 Contained in <br />Sump Su <br />Bucket Diameter <br />Bucket Depth: <br />lb <br />Wait time between applying <br />vacuum"watcr and start of test. - <br />Test Stan Time (Tj): <br />Initial Reading (Rj): <br />15 <br />Test End Time (TF): <br />2 <br />Final Reading (RF): <br />I I <br />Test Duration (TF - Tj): <br />-Ehange <br />IHR <br />in Reading (RF - Rj): <br />0 <br />0, <br />0 <br />El Pass El Fail <br />Pas&?Fail Threshold or <br />Criteria: <br />-Tcst <br />IJ16 <br />1116 <br />1/16 <br />0 Pass 0 Fail <br />Result: <br />0 Pa s's 0 Fail <br />El Pass 0 ]tail <br />UOMMents —011clude information on repairs testing. andrecommen <br />KET FAILF13. RIPON RUBBER PORTION ON CNI WASTE 011, 13UCLKET LID, NF1 I)S REPLACE AND Pw-l-LST. <br />('F.RTIFIC,'t'I*ION'OOtECII-NICIAN RESPONSIBLE FOR CUN511-TURc TRISTUSTING <br />I <br />hereby terfify that all the inform2tiort4contained in this repnrt Is; true, il"UMI&HIld in futlenniplianteuithle-gal requirements_ <br />Technician's Signature- Vlz�—j <br />Date: 5-19-17 <br />'State laws and regulations do not currently require testing to be perforined by a qualified contractor. However, <br />may be more stringent. local requirements <br />