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0 <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(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: 4/5/2018 <br /> Facility Address: 2512 E.WATERLOO ROAD STOCKTON,CA 95219 <br /> Facility Contact: HENG or FONG Phone: <br /> Date Local Agency Was Notified of Testing:3/19/2018 <br /> Name of Local Agency Inspector(f present during testing): CESAR <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: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-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 /> 77 .:.. ,, 777� 777, <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: El Contained in ❑ Contained in <br /> El Contained in Sump El Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1535 1330 1330 <br /> Initial Reading(RI): 13 - 15 11 - <br /> Test End Time(TF): 1635 1430 1430 <br /> Final Reading(RF): 13 - 15 11 <br /> Test Duration(TF-TI): HOUR HOUR HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- <br /> Test Result: 0 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 /> MEASURED ALL 5 GALLONS <br /> REPLACED DRAIN VALVE ASSEMBLY AND"O"RING-87 TANK- RETESTED WITH INSPECTOR <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: O (_ - — Date: 4/5/2018 <br /> 1 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 />