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0 0 0 <br />SWRCB. January 2006 <br />Thisfi.orno as intundedfi)r rose by coniravirirs performing annual testing of UST spill coniahnnent structures. Tire completed form and <br />printouts fret" 10 -vis (if applicablef, should be provided to lhefiaclfity owtwrloperatorfor submittal to the local regidaturT agency, <br />1. FACILITY INFORMATION <br />Facility Name: UNITED PACIFIC 555446 Date of Testing: 51,17 <br />inility Address: 1403 COUNTRY CLUB BLVD STOCKTON, CA 95204 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Tcsflna;411�4/17 <br />Name of Local Agency Inspector (if present during tesfinV: STACY <br />Company Name: AFFORDA TEST 4162m"Street Galt.CA95632 (209) 744.01 Q Fax: (209) 744-0116 <br />Technician; 0 Ed Steams Zane A. Nimmo 0 David A. Winkler 0 Felix G. Ramirez <br />5250492 -UT 52$3322 -LIT 5263373 -UT 5273934 -UT <br />Credentials': [Q ICC Service Tech. SWRCB T—ank T. -,-,;t <br />3. SPILL BUCKE'r TESTING INFORIMATION <br />r7w lvletQ Used: Hvdrostatic r_1 -Vacuum EJ Other <br />-fest 'E'quip�nent Used: TAPE MEASURE <br />Equipment Resolution: 1116 <br />Identify Spill Bucket (Av Tank <br />Number, SioredProduct, etc.) <br />1 87 <br />2 91 <br />3 )SSI, <br />4 <br />I <br />Bucket Installation Type: <br />0 Direct Bury <br />0 Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />El Contained in <br />SumpSum <br />❑ Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />I I <br />I I <br />I I <br />Bucket Depth: <br />12 <br />11 <br />12 <br />Wait time between applying <br />vacuumAvatcr and start of test-. <br />Test Start Time (Tj): <br />1400 <br />1400 <br />1400 <br />Initial Reading (RI). <br />I I <br />1500 <br />1500 <br />Tcst End Time (TF): <br />1500 <br />Final Reading (RE): <br />I I <br />to <br />IHR <br />Test Duration (TF — Ti): <br />IIIR <br />IfIR <br />Chang <br />,c in Reading (Rr - Rl)-- <br />0 <br />0 <br />0 <br />PasslFa­ii i"I'res-hold or <br />Criteria: <br />1/16 <br />1/16 <br />1116 <br />Test Result: <br />Pass []Fail <br />Z Pass El Fail <br />I N Pass 0 Fail <br />El Pass ❑Fall <br />Com, malts — tinchidehijbrmation on repairs made -pricer ter test and recom L e, 1 <br />_k:xm _fulled <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONIAWTING 'I'll l[STESTIN G <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 />Datc:5/1117 <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 />