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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(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 I Date of Testing: 5-1-15 <br /> Facility Address: 4100 FREMONT ST STOCKTON C A <br /> Facility Contact: RICK Phone: .,,. <br /> Date Local Agency Was Notified of Testing:4-30-15 ON 0 8 2015 <br /> Name of Local Agency Inspector(if present during testing): CINDY <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMFNTAI <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 ax: (26 44gf1 <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 /> _ <br /> Identify Spill Bucket(By Tank 1 2 91 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑ Contained in Sump ❑Contained in Sump ❑Contained in <br /> Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12.50 <br /> Wait time between applying -- _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 840 <br /> Initial Reading(RI): 12.50 <br /> Test End Time(TF): 940 <br /> Final Reading(RF): 12.50 <br /> Test Duration(TF—TO: IHR <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or 1/16 <br /> Criteria: <br /> Test Result: PASS ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Retest on 91 from failure on 4-23-15 .Passed today. <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: 5-1-15 <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 />