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0 <br /> 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: GREWALS GASDate of Testing: 4-26-2012 <br /> Facility Address: 4100 FREMONT ST STOCKTON C A <br /> Facility Contact: RICK Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(i(present during testing): JEFF <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d 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 /> Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank^ 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: ElContained in F1Contained in <br /> ElContained in Sump E]Contained in Sump SumpSum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 11.25 12.50 15.25 <br /> Wait time between applying _- -- <br /> vacuutn/water and start of test: <br /> Test Start Time(T,): 12 12 12 <br /> Initial Reading(R1): 11 12 14.50 <br /> Test End Time(TF): I 1 1 <br /> Final Reading(RF): 11 12 14.40 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ❑.Felt ,Pass_ .❑:fall ❑,>'' ❑ 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: Tz�--j Date 4-26-2012 <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 />