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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: 4-24-13 <br /> Facility Address: 2512 E. WATERLOO RD. STOCKTON, CA 95219 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/9/13 <br /> Name of Local Agency Inspector(zf present during testing): 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 E] Felix G.Ramirez <br /> 5249115-UT 5263322-UT 526337.. 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> 7'772L=122'Q-44, "MIM <br /> r.. <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: ®Direct Bury El Direct Bury [:]Contained in ❑ Contained in <br /> El Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 i l 11 <br /> Bucket Depth: 18 15 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 0920 0945 0920 <br /> Initial Reading(R j): 16 12 1/2 11 <br /> Test End Time(TF): 1020 1045 1020 <br /> Final Reading(RF): 16 12 1/2 11 <br /> Test Duration(TF—TI): HR HR HR HR <br /> Change in Reading(RF-RI): <br /> Pass/Fail Threshold or <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 /> 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 e Date: 4-24-13 <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 />