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Fj (-;E,-, V LU <br /> ' j U N '� 6 AWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill con )#& I t corm and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submitt _ 0, _ latory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: GREWALS GAS AND LIQUOR Date of Testing: 04-6-17 <br /> Facility Address: 4100 EAST FREMONT ST STOCKTON CA <br /> Facility Contact: RICK Phone: 209-487-0480 <br /> Date Local Agency Was Notified of Testing:03-20-17 <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO VICKI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211 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 /> 8184188 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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑ Contained in <br /> ❑ Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 11 12 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 910 910 910 <br /> Initial Reading(Ri): 11 12 15 <br /> Test End Time(TF): 1010 1010 1010 <br /> Final Reading(RF): 10 1/2 12 15 <br /> Test Duration(TF—Ti): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 1/2 INCH 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ❑ Pass 0 Fail 10 Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑ Fail i <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> 87 BUCKETS DOES NOT HAVE 5 GALLON CAPACITY-REPAIR AND RETEST NEEDED <br /> 91 AND DIESEL BUCKET HOLD 5 GALLON CAPACITY <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:04-06-17 <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 />