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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tulare Farms Date of Te Irl„7, <br /> Facility Address: 2771 E FRENCH CAMP RD FRENCH CAMP CA s 7,04 <br /> Facility Contact: Mike Phone: I IL <br /> Date Local Agency Was Notified of Testing :12-22-16 <br /> Name of Local Agency Inspector(if present during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATIONFNVIRONMENTAL HEALTH <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-01 QFFFMA TPA- 116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo M 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 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury El Direct Bury ®Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑Contained in El Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 2 2 2 <br /> Initial Reading(RI): 14 14 <br /> Test End Time(TF): 3 3 <br /> Final Reading(RF): 11 12 14.40 <br /> Test Duration(TF—Ti): 1 HR IHR IHR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <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 /> OPW <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: T Date 1-17-17 <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 />