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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. FACILITY INFORMATION <br /> Facility Name: GREWAL'S GAS I Date of Testing: 4/16/14 <br /> Facility Address: 4100 E. FREMONT ST. STOCKTON, CA 95215 <br /> Facility Contact: RICK Phone: <br /> Date Local Agency Was Notified of Testing:3/10/14 <br /> Name of Local Agency Inspector(ifpresent during testing): JEFF WONG <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 /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑ Direct Bury ®Direct Bury ® Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> ` <br /> El Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 11 1/4 12 3/8 15 1/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1420 1420 1420 <br /> Initial Reading(Ri): 10 1/4 11 3/8 14 1/4 <br /> Test End Time(TF): 1520 1520 1520 <br /> Final Reading(RF): 10 1/4 11 3/8 14 1/4 <br /> Test Duration(TF—Tj): HR HR HR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail` ❑ Pass ❑Fail 0 Pass ❑ Fail 0 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 CbONDUCTING 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: Date: 4-16-14 <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 />