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is <br /> SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for itse vy contractors perfor7))ing annual testing of UST spill contain?) it sty t ores. The completed form and <br /> pfintouts fro?) tests (ifapplicable), should be provided to the facility otrner/operator for sub? i(tal )te local regulai'my agency. <br /> 1. FACILITY I_NWORMATION <br /> Facility Name: TRACY 76 Date osf g 5-22-18 <br /> Facility Address: 2420 W. GRANTLINE RD, TRACY, CA 95376 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: — <br /> Name of Local Agency Inspector (if present diming testing) : STACY <br /> 2. TESTING CONTRACTOR INFORMATII IN <br /> Company Name: AFFORDA TEST 416 2id Street Galt, CA 95632 209) 71 4-O112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns El ZaneA. Nimmo David A. W ikler F1Felix Ramirez <br /> 8883080-UT 8883064 UT 8883059- i , , _. <br /> Credentialsi : ® ICC Service Tech. © SWRCB Tank Tester ! <br /> 3. SPILL BUCKET TESTING INT4 ORAMATI ON <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Oth <br /> Test Equipment Used: 1120 and tape measure Equipe nt R solution: 1116 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Pfod?et, etc.) <br /> ® DIrtBuy E] Direct Bury <br /> © Direct Bury ® Direct Bury ❑ Co) 1 ,i i E] Contained in <br /> Bucket Installation Type: E] Contained in Sump ❑ Contained in Sump Sump Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying - -- <br /> vaeuunttwater and start of test: <br /> Test Start Time (Ti): 930 930 930 <br /> Initial Reading (Ri) : 14 14 14 <br /> Test End Time (TF): 1030 1030 1030 <br /> Final Reading (RF): 14 14 ! 4 <br /> Test Duration (TF - TI): iHR 1HR IHR <br /> Change in Reading (RF - Rl): 0 0 0 <br /> Pass/Fail Threshold or 1/ 16 1/ 16 1 / 16 <br /> Criteria: <br /> Test 'Result © Pass El Fail ® Pass ❑ Fall ® 3s . 4FM1pass ❑ Fail <br /> Comments — (include irlfor7)jation on repairs uu)de prior to testing, and recon?nended f ut-i p for failed tests) <br /> QPW FLAPPERS <br /> CERTIFICATION OF TECINICM\ RESPO\SIBLE FOR COitDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is time, accurate, and in full compliance ii li lege t quiremenls. <br /> ( f Date 5-224 <br /> Technician's Signature: V � <br /> I State laws and regulations do not currently require testing to be performed by a qualifie ontz c or. Hotivever, local requirements <br /> may be more stringent. <br />