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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 GAS Date of Testing: 4-17-13 <br /> Facility Address: 4100 FREMONT ST STOCKTON C A <br /> Facility Contact: RICK Phone: <br /> Date Local Agency Was Notified of Testing A-1-13 <br /> Name of Local Agency Inspector(if present during testing): JEFF <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: 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 /> Bucket Installation Type: <br /> ®Direct Bury ®Direct Bury ®Direct Bury ElDirect Bury <br /> El Contained in Sump El Contained in Sump El Contained in ❑Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 i l 11 <br /> Bucket Depth: 11.25 12.50 15.25 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12 12 12 <br /> Initial Reading(R): 11 12 15 <br /> Test End Time(TF): 1 1 1 <br /> Final Reading(RF): 11 12 15 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result. 0 Pass ❑Fail ® Pass ❑Fail E Pass ❑Fail ❑ 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: Date 4-17-2013 <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 />