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SEP 1 1 20 &RCB, January 2006 Spill Bucket Testing Report Form ENVIPONME AL This form is intendedfor use by contractors pezforming annual testing of UST spill conta�a nt j r ��cq letedform and printouts from tests (f applicable), should be provided to the facility owner/operator for t the oc gu atory agency. 1. FACiLiTY INFORMATION 2. TF,STiNG CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2°d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT Credentials': ®ICC Service Tech. ®SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic ❑Vacuum [I Other Comments — (inclzzde information on repairs made prior to testing, and recommended follow-up for failed tests) OPAI Test Equipment Used: TAPE MEASURE , H 2 0 Equipment Resolution: 1/16" Facility Name: Facility Address: ANGLE - 99 SHELL I Date of Testing: 8-3048 7700 MORELAND CT. STOCKTON, CA 95212 Facility Contact: ANGLE Phone: 209-957-5398 Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): STACY 2. TF,STiNG CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2°d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT Credentials': ®ICC Service Tech. ®SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic ❑Vacuum [I Other Comments — (inclzzde information on repairs made prior to testing, and recommended follow-up for failed tests) OPAI Test Equipment Used: TAPE MEASURE , H 2 0 Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 91 3 DIESEL 2 4 Bucket Installation Type: ❑ Direct Bury ®Contained in Sump ❑Direct Bury ®Contained in Sump ❑Direct Bury ® Contained in SumpSum ❑Direct Bury ❑ Contained in Bucket Diameter: 11 11 Bucket Depth: 14 1/4 16 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 9 11 Initial Reading (RI): 13.50 15 Test End Time (TF): 10 12 Final Reading (RF): 13.50 15 Test Duration (TF — TI): HOUR HOUR Change in Reading (RF - RI): 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fail Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail I DID NOT TEST 91 UNDER CONSTRUCTION CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.