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J tJ 1 0 SB, January 2006 <br />Spill Bucket Testing Report Form <br />Thisform is intended or use b contractorsperformingannual testing o UST spill containment " mI�TJ' <br />f f Y g f P �td form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for subriittu? Ciie �bcaegu Tory agency. <br />1_ FAC'II.ITV INMRMATMN <br />Facility Name: PARKWOOD GAS & FOOD SHELL Date of Testing: 5-15-18 <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: <br />Name of Local Agency Inspector (f present during testing): AARON <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd 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 />8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT <br />I Credentials: ® ICC Service Tech. ® SWRCB Tank Tester A <br />3. SPII,I, RTICKFT TF,CTTNC_ TNFCIRMATInN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / <br />H2O <br />Equipment Resolution: 1/16 <br />"12 217, 17 777 <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 />El Contained in Sump <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />El Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />I 1 <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 />- <br />Test Start Time (Ti): <br />12 <br />12 <br />12 <br />Initial Reading (Ri): <br />13 1/2 <br />131/2 <br />13 <br />Test End Time (TF): <br />1 <br />1 <br />1 <br />Final Reading (RF): <br />13 1/2 <br />131/2 <br />13 <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 />- <br />- <br />Test Result: <br />® Pass ❑ Fail <br />0 Pass ❑ Fail <br />0 Pass ❑ Fail <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: W <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 />