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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <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 local regulatory agency. <br />1 Ti Af`TT TTV TN nD1%4ATTnN <br />Facility Name: PARKWOOD VALERO I Date of Testing: 7/28/11 <br />Facility Address: 1612 W. HAMMER LANE STOCKTON CA 95210 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing :6/24/11 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN COUNTY <br />2_ TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ® Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />IICredentials': ❑ ICC Service Tech. ❑ SWRCB Tank Tester 11 <br />A CPTT.T. RTTCWVT TTCTINf_ INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE, H2O <br />Equipment Resolution: 1/16" <br />3 91 <br />4 DIE <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc.) <br />2 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ ontained in S mp <br />® Direct Bury <br />❑ 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 />14 1/2" <br />15 <br />16 <br />Wait time between applying <br />vacuum/water and start of test: <br />--- <br />---- <br />----- <br />Test Start Time (Ti): <br />1535 <br />1535 <br />1535 <br />Initial Reading (Ri): <br />133/4 <br />141/2 <br />15 5/8 <br />Test End Time (TF): <br />1635 <br />1635 <br />1635 <br />Final Reading (RF): <br />Test Duration (TF — TI): <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />----------- <br />----------- <br />------------ <br />Test Result: <br />®,Pass ❑ Fail <br />❑ Pass'' ❑ Fail <br />® Pass ❑ Fail <br />® 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: 4a;" <br />Date: 7/28/11 <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 />