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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> I'lus form is intendedfor use by contractors performing annual testing MUST spill containment structures. The completed farm rind <br /> iyi,atout.s/ivom tests (if applicable), should be provided to the facility orvrler/operator for submittal to the local regulatory agent_,. <br /> 1. FACILITY INFORMATION <br /> -_-- i Date of Testing: 4-29-'10 <br /> I Facility Name: GREWALS 76 <br /> Facility Address: 4100 E FREMONT STREET STOCKT01� CA <br /> Facility Contact: ----RICK Phone: <br /> ---_ _ <br /> Date Local Agency Was Notified of Testing - <br /> Mime of Local Agency Inspector (iI'present during testing)' JEFF <br /> _ 2. TESTING CONTRACT R INFORMATION __--- <br /> _ <br /> �' Company Name: AFFORDA TEST 416 7_ Street Galt, CA:95632 (209) 744-0112 Fax <br /> (209) 741 O l I <br /> -- I <br /> I echnician Conducting Test: F-1Lyle D. Nimmo ❑ Zane A. Nirnmo ❑ David A. Winkler [] Felix G. Ramirez <br /> il <br /> 5249115-UT 5263322-UT 5263373-UT 5273934 UT — <br /> (,'redentials': ICC Service Tech. ® SWRCB Tank Tester <br /> 3 SPILL BUCKET TESTING INFORMATION <br /> Otnei <br /> 1 est Method Used: ® Hydrostatic — El Vacuum l_I - <br /> Iest Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> --- 2 91 3 DSL 4 <br /> Identify Spill Bucket (By Tank 1 87 <br /> \'umber, Stored Product, etc.) - - - <br /> _- - ® Direct Bury ❑ Direct Bur} <br /> ® Direct Bury ® Direct Butt' ❑ Contained in ❑ Contained in <br /> Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump Sum <br /> Sump _ P _.. <br /> i LIcket Diameter: 1 1 1 1 - <br /> --- 12 1511 �I <br /> BLIcket Depth: <br /> _ <br /> Wait time between applying <br /> - <br /> UCLIurn/water and start of test: <br /> __- -. — 1145 <br /> Fest Start"Time14 <br /> h 1 145 1 145 --- - <br /> Initial Reading(R,): 10 - <br /> __ - 124 5 1245 <br /> I cst End Time (T,-): 1245 _ ------ <br /> - - 14 <br /> 1-'incl Reading(Rr): 10 <br /> best Duration (Tr -T,): 1 HR IHR _ -- --- <br /> Change in Reading(R�-Rt): 0 0 <br /> Pass/Fail "Threshold or 1/16 1/16 1/16 --- - <br /> j Criteria: <br /> Pass Fail ® Pass ;❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail I) <br /> j-Test Result: ® ❑ - - <br /> Comments - (include information on repairs made prior to testing, rind recommended follow-up for,failed tests) _.. <br /> — CLarrtrtcA,rtON OF TECHNICIAN RESPONSIBLE Foil CON'DUCTING3HIS 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: v " Date 4-29-2010 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. I-lowever, local requirements <br /> may be more stringent. <br /> I <br />