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I <br />F <br />SWR CB, 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: PACIFIC CAR WASH Date of Testing: 5/14/15 <br />Facility Address: 4405 PACIFIC AVE. STOCKTON, CA 95207 <br />Facility Contact: TAMMI Phone: <br />Date Local Agency Was Notified of Testing :4/22/15 <br />Name of Local Agency Inspector (if present during testing: Fatinah <br />2. TESTING CONTRACTOR INFORMATION . 4 <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 F ax-(2091744*1 %6 ° - <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. Z SWRCB Tank Tester <br />Test Method Used: ®Hydrostatic❑ Vacuum ❑Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />® Direct Bury <br />Bucket Installation Type:❑ <br />❑Contained in Sump <br />2 <br />❑ Direct Bury <br />❑Contained in Sump <br />Equipment Resolution: <br />3 91 <br />Direct Bury <br />Contained in <br />Sump <br />1/16" <br />4 <br />Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />Bucket Depth: 14 5/8 <br />15 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): 0915 <br />0915 <br />Initial Reading (RI): 14 <br />14 <br />Test End Time (TF): 1015 <br />1015 <br />Final Reading (RF): 14 <br />14 <br />Test Duration (TF — TI): HR <br />HR <br />Change in Reading (RF - RI): 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />I" F <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 Date: 5-14-15 <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 />