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Spill Bucket Testing Report Form AUG 0 6 20WRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill contain m �{{\\��;; c inpleted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for subilt � ltory agency. <br /> HEAD ~ <br /> 1.FACILITY INFORMATION <br /> Facility Name: EMILS LIQUOR& SPORTS SHOP Date of Testing: 6/27/18 <br /> Facility Address: 1405 CALIFORNIA ST. ESCALON,CA 95320 <br /> Facility Contact: CHACKO Phone: <br /> Date Local Agency Was Notified of Testing:5/21/18 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"1 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 MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury E]Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury El Contained in E] Contained in <br /> El Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 133/4 13 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 0900 0900 0900 <br /> Initial Reading(RI): 12 12 13 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 12 12 13 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-Rr): 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 /> Diesel spill bucket failed. Could not locate leak Needs contractor to replace or repair then retest. <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 /> 7 <br /> Technician's Signature: 6f—jj- =_. Date:6/27/18 <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 />