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® SWRCB,January 2006 <br /> Spill Bucket Testing Report <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: WATERLOO LIQUOR I Date of Testing: 04-21-14 <br /> Facility Address: 2512 EAST WATERLOO RD STOCKTON CA 95205 <br /> Facility Contact: HENG Phone: 209-463-4114 <br /> Date Local Agency Was Notified of Testing:03-12-14 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO JEFF WONG <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: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc) <br /> ®Direct Bury ®Direct Bury ® Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sum Sum <br /> p <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying _ - <br /> vacuum/water and start of test: j <br /> Test Start Time(Ti): 1030 1030 i <br /> Initial Reading(RI): 1 12 12 j <br /> Test End Time(TF): 1130 1130 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Pass „ ❑',Fail Q Pass ❑Fail0 Pass ❑Fail j ❑ Pass ❑ "ail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> 91 BUCKET NOT TESTED.NOT READY FOR TESTEING, TO BE TESTED BY ELITE IV TODAY. <br /> 4-21-14 SEE ATTACHED REPORT FROM SPILL BUCKET TET ON 9 1. <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:04-21-14 <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 />