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e <br /> S January 2006 <br /> Spill Bucket Testing Report Form JUN <br /> w tot <br /> This form is intended for use by contractors performing annual testing of UST spill containment str`uGturc,� kt caMleted 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: TWO GUYS VALERO I Date of Testing: 06-07-16 <br /> Facility Address: 147 E LATHROP RD LATHROP CA 95330 <br /> Facility Contact: GREG I Phone: 209-858-2666 <br /> Date Local Agency Was Notified of Testing A-28-16 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO.VICKY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"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: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury E] Direct Bury <br /> Bucket Installation Type: El Contained in Sump F1 Contained in Sump El Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tr): 900 900 900 <br /> Initial Reading(Ri): 12 12 12 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 12 12 12 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> [Criteria. <br /> Test Result. ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS HOLD 5 GALLONS <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:06-07-16 <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 />