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ft ft <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: CITY OF STOCKTON CORP YARD Date of Testing: 4-7-17 <br /> Facility Address: 1465 S LINCOLN ST STOCKTON CA <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:3-27-17 <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 21d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: DED 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 3 DSL <br /> Number, Stored Product, etc.) <br /> ®Direct Bury <br /> Bucket Installation Type: ®Direct Bury ❑Contained in <br /> ❑ Contained in Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth. 15 17 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 937 937 <br /> Initial Reading(RI): 14 16 <br /> Test End Time(TF): 937 937 <br /> Final Reading(RF): 14 16 <br /> Test Duration(TF—Ti): IHR IHR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> Criteria: <br /> Test Resit: PASS PASS <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 /> T�� <br /> Technician's Signature: Date 4-7-17 <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 />