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s <br />R E <br />Spill Bucket Testing Report Form <br />MAY MR, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill contain r ; 4 11��1 and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for su i t lid°ld� dtd <br />1. FACILITY INFORMATION <br />Facility Name: PARKWOOD SHELL I Date of Testing: 5-9-17 <br />Facility Address: 1612 W HAMMER LANE STOCKTON CA 95209 <br />Facility Contact: PAUL Phone: 209-931-3549 <br />Date Local Agency Was Notified of Testing A-20-17 <br />Name of Local Agency Inspector (fpresent during testing): VICKI <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 211 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 />I) Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sum <br />❑ Direct Bury <br />® Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />141/2 <br />14 1/2 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1130 <br />1130 <br />1130 <br />Initial Reading (RI): <br />141/2 <br />141/2 <br />14 <br />Test End Time (TF): <br />1230 <br />1 1230 <br />1230 <br />Final Reading (RF): <br />141/2 <br />141/2 <br />14 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result. <br />® <br />Pass ❑ <br />Fail <br />I ED <br />Pass ❑ Fail <br />Z Pass <br />❑ Fail <br />❑ <br />Pass [❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <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 />