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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: WATERLOO LIQUORS Date of Testing: 0 <br /> Facility Address: 2512 E WATERLOO RD STOCKTON CA <br /> Facility Contact: Phone: MAY 19 <br /> Date Local Agency Was Notified of Testing A-20-14 <br /> Name of Local Agency Inspector(f present during testing): <br /> '1C:1D40TAA!ZNT <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 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 I Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number,Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: 1771 Contained in El Contained in <br /> ❑ Contained in Sump ❑Contained in Sump 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(Ti): 9 9 9 <br /> Initial Reading(Rj): 13 12 13 <br /> Test End Time(TF): 13 10 10 <br /> Final Reading(RF): 11 12 13 <br /> Test Duration(TF—Ti): IHR IHR IHR <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 N Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> P. T 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 4-20-15 <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 />