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0 9 <br />SWRCB, January 2006 <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: 05-19-14 <br />Facility Address: 4405 PACIFIC AVE STOCKTON CA 95207 <br />Facility Contact: Greg I Phone: 209-478-5504 <br />Date Local Agency Was Notified of Testing :04-14-14 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO JEFF WONG <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 />H Credentials': [9 ICC Service Tech. ® SWRCB Tank Tester . II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc.) <br />2 91 <br />3 <br />4 <br />® Direct Bury <br />Bucket Installation Type:F] <br />❑Contained in Sump <br />® Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />Contained in <br />Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />Bucket Depth: 13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): 935 <br />935 <br />Initial Reading (Rj): 12 <br />12 <br />Test End Time (TF): 1035 <br />1035 <br />Final Reading (RF): 12 <br />12 <br />Test Duration (TF — Tj): 1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result. ® <br />Pass ❑ Fail <br />1 ® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass El Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW BUCKETS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained i <br />