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CJ <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SAN JOAQUIN CO. -- DOWNTOWN GARAGE ' Date of Testing: 7/30/12 <br />Facility Address: 121 S. SAN JOAQUIN ST. STOCKTON, CA 95202 <br />Facility Contact: CONNIE Phone: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (f present during testing): GARRET BACKUS <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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, <br />.......x, n .... , x\ ..... ... <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />H2O Equipment Resolution: <br />.... ., ,.................i .. <br />1 87 2 3 <br />Direct Bury <br />® Direct Bury F-1 Direct Bury El Contained in <br />❑Contained in Sump ❑Contained in Sump Sum <br />1/16" <br />4 <br />Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />22 <br />Bucket Depth: <br />17 3/8 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />1215 <br />Initial Reading (RI): <br />17 3/8 <br />Test End Time (TF): <br />1315 <br />Final Reading (RF): <br />17 3/8 <br />Test Duration (TF — Tj): <br />HR <br />HR HR <br />HR <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ 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: OVO-f — — <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 />