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. . . <br />C <br />JUN ifJanuary 2006 <br />Spill Bucket Testing Report Form _ <br />This form is intended for use by contractors performing annual testing of UST spill containment strucfurek TRtcb*mpletedjbrm 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: PACIFIC CAR WASH Date of Testing: 05-23-16 <br />Facility Address: 4405 PACIFIC AVE STOCKTON CA 95207 <br />Facility Contact: TAMMY Phone: 209-478-5504 <br />Date Local Agency Was Notified of Testing :04-26-16 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO Fatinah <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"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 />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other I <br />Test Equipment Used: TAPE / H2O I Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank 1 87 2 91 3 4 <br />Number, Stored Product, etc) <br />® Direct Bury ® Direct Bury ❑ Direct Bury El Direct Bury <br />Bucket Installation Type: El Contained in ❑ Contained in <br />❑ Contained in Sump ❑ Contained in Sump I c....... c....... <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />912 <br />912 <br />Initial Reading (Ri): <br />12 <br />12 <br />Test End Time (TF): <br />1012 <br />1012 <br />Final Reading (RF): <br />12 <br />12 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <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: <br />Date:05-23-16 <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 />