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UN 0j <br /> Spill Bucket Testing Report Form J <br /> 20 RCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containm nt strucru �;�Y°he completed form and <br /> ,:m .� . <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: CITY OF STOCKTON CORP YARD Date of Testing: 4-21-2016 <br /> Facility Address: 1465 S LINCOLN ST STOCKTON CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): stacy <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2,d 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 3 DSL 4 dsl retest <br /> Number, Stored Product, etc) <br /> ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ®Direct Bury ❑Direct Bury F]Contained in ❑ Contained in <br /> El Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: 11 I I 11 <br /> Bucket Depth: 15 17 17 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 120 120 2 <br /> Initial Reading(RI): 14 16 17 <br /> Test End Time(TF): 220 220 3 <br /> Final Reading(RF): 13.50 12 15 17 <br /> Test Duration(TF—Ti): IHR IHR IHR 1 hr <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: INCOMPLETE ❑ 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 4-21-2016 <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 />