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RED_ <br /> Q��j 5 2018 <br /> CB,January 2006 <br /> -Spill Bucket Testing Report Form <br /> MENTAL HEALTH <br /> This form is intended for use by contractors performing annual testing of UST spill containment"stMttL'tllre t rm and <br /> printouts from tests(tf applicable), should be provided to the facility owner/operator for submittal to the a e ory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHORT STOP 76 Date of Testing: 9-17-18 <br /> Facility Address: 20 W TURNER RD LODI CA <br /> Facility Contact: Phone: 209-369-3697 <br /> Date Local Agency Was Notified of Testing:8/23/18 <br /> Name of Local Agency Inspector(f present during testing): STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Stearns ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-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: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> ❑ Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 16 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10 10 10 <br /> Initial Reading(RI): 12 12 15 <br /> Test End Time(TF): 11 11 11 <br /> Final Reading(RF): 12 12 15 <br /> Test Duration(TF—TI): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <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 /> 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: W Date:09-25-14 <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 />