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11 <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: TWO GUYS VALERO I Date of Testing: 07-12-11 <br />Facility Address: 147 E LATHROP RD LATHROP CA 95330 <br />Facility Contact: GREG Phone: 209-858-2666 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO. Thuy <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd 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: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />1 87 <br />® Direct Bury <br />❑ Contained in Sump <br />2 91 <br />® Direct Bury <br />❑ Contained in Sump <br />3 DIE <br />Direct Bury <br />❑ Contained in <br />SumpSum <br />4 <br />Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />11 <br />11 <br />I 1 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />1203 <br />1203 <br />1203 <br />Initial Reading (RI): <br />113/4 <br />12 1/8 <br />121/4 <br />Test End Time (TF): <br />1403 <br />1403 <br />1403 <br />Final Reading (RF): <br />113/4 <br />121/8 <br />121/4 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />2 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />❑ ail, <br />Pass F <br />® Pass, ❑ Fail <br />0 Pass ❑Fait' <br />❑ Pass <br />❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <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:07-12-11 <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 />